process improvement in a physiotherapy outpatient setting · design. the terminology used to...
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Process Improvement in a Physiotherapy Outpatient
Setting
Marie Byrne
2013
A Dissertation submitted to the University of Dublin, in partial
fulfilment of the requirements for the Degree of Masters in Science in
Health Informatics
i
Declaration
I declare that the work described in this dissertation is, except where
otherwise stated, entirely my own work, and has not been submitted as an
exercise for a degree at this or any other university.
Signed: _____________________
Marie Byrne
Date: _______________________
ii
Permission to lend and/or copy
I agree that the School of Computer Science and
Statistics, Trinity College may lend or copy this
dissertation upon request.
Signed: ___________________
Marie Byrne
9th August 2013
iii
Acknowledgements
I would like to take this opportunity to say thank you to all those who
encouraged and helped me in a variety of ways to complete this research.
I would first like to thank all participants. A special thank you goes to all of
the physiotherapy and the information technology staff for facilitating and
supporting me.
I am also very grateful to my supervisor Lucy Hederman for all her queries
and suggestions and to all the lecturers who guided me throughout the two
years of the course.
I would like to give my special thanks to the two most important men in my
life; my husband Stuart and son Jack who with their love, sense of fun and
unending patience enabled completion of this dissertation and kept me
focused on the important things in life.
A huge thank you to my sister Briege for the extremely valuable feedback
along the way both on my dissertation and on keeping focused on life’s
priorities. Finally, to my parents; Mary and Frank and all other family
members and friends for their encouragement.
iv
Summary
The requirement to do more with less in the current healthcare environment
has led healthcare professionals to look at the potential opportunities
provided by process improvement methodologies. In the main, these
methodologies have their origins in the manufacturing industry and provide
an alternative way to look at healthcare, away from profession or disease
specific initiatives and toward the processes of the patient journey. Rather
than doing more with less process improvement can lead to the elimination
of unnecessary processes and measurable improvements in quality.
The question this research wished to answer was how processes could be
improved in a physiotherapy outpatients setting. The first phase of
answering this question involved carrying out a literature review to
determine current prevalent process improvement methodologies in use in
healthcare and how processes have been improved at other sites through
the application of such methodologies. The literature also outlined some
potential benefits and perceived challenges. From the literature the
researcher determined that a process improvement methodology based on
the principles of Lean Thinking was appropriate for use in the case under
study. In conjunction with the literature review baseline data was collected
by the researcher. Next the process improvement methodology was applied
in the physiotherapy outpatient department. This was done in three stages:
process mapping through observation, interviews with key physiotherapy
informants and a staff focus group. These three stages pinpointed which
parts of the process should be improved and how, the potential benefits
these improvements could have on the quality of the patient journey and
some possible challenges.
While the scope of this research was not to implement the suggested
process improvements some of the suggested improvements have been
v
progressed and others are planned. Those progressed have had a significant
impact on the baseline data whereby no patient waited for an orthopaedic
or rheumatology appointment for the three months following clarification of
the booking policy (I1)1 (figures 5.2 to 5.4). A possible future process map
and key repositories are also presented based on the improvements
suggested (figure 5.7 and 5.8). As can be seen, figure 5.8 shows the
potential for a dramatic reduction in the reliance on paper. This has already
begun with the elimination of the printing of 5,500 front sheets each year
(section 5.4.1).
The literature emphasises the need to begin by reviewing processes, and to
use data to determine the focus of improvement, and to highlight if any
change is indeed an improvement. The literature also recommends that
processes are improved in so far as possible before the introduction of
health information technology (IT) to avoid automation of outdated
processes. At the same time, the role of IT in simplifying and standardising
processes and ultimately in sustaining improvement is also acknowledged.
This research demonstrated that the staff who participated clearly
acknowledged the role IT has in this regard. Highlighting the benefits
realised elsewhere and the baseline data had a noticeable impact on staff
engagement. Challenges outlined in the literature and through the
interviews are important to be aware of to allow for change management
strategies to be put in place.
The literature also highlights, that while there are case studies outlining
various methodologies, the tools and methodologies used are sometimes
not clearly stated and some authors have called for more rigorous study
design. The terminology used to describe Lean Thinking interventions also
varies as some organisations have adapted Lean Thinking principles to their
local context.
1 I1,2,3 etc. refer to the suggested improvements/point in the workflow outlined in Chapter 5.
vi
In conclusion, the use of process improvement and information technology
in physiotherapy has not been cited extensively. However, numerous case
studies are available elsewhere in healthcare. This research demonstrates
that a process improvement methodology based on Lean Thinking principles
can be applied in a physiotherapy outpatient setting to determine how
processes could be improved. Data collection and staff engagement at all
stages have been and will continue to be crucial.
vii
Table of Contents
Declaration .......................................................................................... i
Permission to lend and/or copy ............................................................. ii
Acknowledgements .............................................................................. iii
Summary .......................................................................................... iv
Table of Contents ............................................................................... vii
List of Tables ..................................................................................... xii
List of Figures ................................................................................... xiii
Abbreviations ....................................................................................xv
Glossary of Terms ............................................................................. xvi
CHAPTER 1 ......................................................................................... 1
INTRODUCTION .................................................................................. 1
1.1 Study Context ............................................................................ 1
1.1.1 National Context ................................................................... 5
1.1.1.1 HSE CompStat................................................................. 6
1.1.1.2 HSE National Clinical Programmes (NCP) ............................ 6
1.1.1.3 Health Information and Quality Authority Standards ............. 7
1.2 Research Questions ..................................................................... 7
1.3 Motivation for the Research .......................................................... 8
1.4 Overview of the Research ............................................................ 8
1.5 Overview of the Dissertation ........................................................ 9
CHAPTER 2 ....................................................................................... 10
LITERATURE REVIEW ......................................................................... 10
2.1 Introduction ............................................................................. 10
2.1.1 Literature Search Strategy ................................................... 12
viii
2.2 Process Improvement in Healthcare ............................................ 13
2.2.1 What is Process Improvement in Healthcare? .......................... 14
2.2.2 Levers for Process Improvement in Healthcare ........................ 16
2.3 Methodologies in Process Improvement in Healthcare .................... 17
2.3.1 Lean Thinking ..................................................................... 18
2.3.2 Six Sigma ........................................................................... 21
2.3.3 Plan-Do-Study-Act (PDSA) ................................................... 22
2.4 Measurement in Process Improvement in Healthcare ..................... 23
2.5 Tools used to Understand and Improve Processes ......................... 24
2.5.1 Process Mapping ................................................................. 25
2.5.2 Focus Groups and Interviews ................................................ 28
2.5.3 Fishbone Diagrams .............................................................. 29
2.5.4 Data Check Sheets .............................................................. 30
2.5.5 Statistical Control Chart ....................................................... 30
2.5.6 Summary ........................................................................... 31
2.6 Case Studies ............................................................................ 32
2.7 Process Improvement based on the introduction of Information
Technology .................................................................................... 36
2.8 Process Improvement and the introduction of Information Technology
for Physiotherapists ........................................................................ 38
2.9 Challenges to Process Improvement ............................................ 42
2.10 Change Management ............................................................... 45
2.11 Conclusion ............................................................................. 46
CHAPTER 3 ....................................................................................... 48
RESEARCH METHODOLOGY ................................................................ 48
3.1 Introduction ............................................................................. 48
ix
3.2 Background .............................................................................. 49
3.3 Study design ............................................................................ 49
3.4 Methodology ............................................................................ 50
3.4.1 Stage 1: Process mapping .................................................... 51
3.4.2 Stage 2: Semi-structured interviews ...................................... 54
3.4.3 Stage 3: Focus group ........................................................... 55
3.5 Participants and recruitment methods ......................................... 58
3.6 Ethics application ...................................................................... 58
3.7 Conclusion ............................................................................... 58
CHAPTER 4 ....................................................................................... 60
RESULTS .......................................................................................... 60
4.1 Introduction ............................................................................. 60
4.2 Baseline data ........................................................................... 60
4.2.1 Throughput ........................................................................ 61
4.2.2 Retrieval and filing of physiotherapy notes ............................. 62
4.2.3 Phone calls ......................................................................... 62
4.2.4 Costs of paper and storage ................................................... 63
4.3 Process Maps ........................................................................... 63
4.4 Semi-structured interviews ........................................................ 92
4.4.1 Suggested Improvements arising from interviews ................... 93
4.4.2 Potential Benefits as identified by interviews ........................... 96
4.4.3 Perceived Challenges as identified by interviews ...................... 97
4.5 Focus Group ............................................................................. 98
4.6 Conclusion ..............................................................................102
x
CHAPTER 5 ......................................................................................104
ANALYSIS AND DISCUSSION .............................................................104
5.1 Introduction ............................................................................104
5.2 Research questions ..................................................................104
5.3 Findings ..................................................................................104
5.3.1 What process improvement methodology is appropriate to apply
in the physiotherapy outpatient setting? (SQ1) ..............................105
5.3.2 Which processes should be improved? (SQ2) .........................106
5.3.3 How can processes be improved in a physiotherapy outpatients
setting? (SQ3)............................................................................109
5.3.4 What are the potential benefits of any suggested improvements?
(SQ4) ........................................................................................112
5.3.5 What are the perceived challenges of any suggested
improvements? (SQ5) .................................................................113
5.3.6 Conclusion to Research Questions ........................................113
5.4 Progress and Plans for Suggested Improvements .........................114
5.4.1 Progress made to date ........................................................114
5.4.2 Plans for the future .............................................................118
5.4.3 Suggested improvements that cannot be progressed or have not
been progressed to date ..............................................................123
5.4.4 Proposals to address challenges ...........................................125
5.5 Conclusion ..............................................................................125
CHAPTER 6 ......................................................................................126
CONCLUSION ..................................................................................126
6.1 Introduction ............................................................................126
6.2 Recommendations for Future Research .......................................126
xi
6.3 Study limitations ......................................................................127
6.4 Conclusion ..............................................................................128
References ......................................................................................130
Bibliography ....................................................................................151
Appendices ......................................................................................153
Appendix A: Overview of physiotherapy ........................................154
Appendix B: Protocol for semi-structured interviews with experts .....158
Appendix C: Consent Form ..........................................................159
Appendix D: Participant Information Sheets ...................................162
Appendix E: Ethics ......................................................................169
Appendix F: Key to notations on process maps ...............................172
Appendix G: Stakeholder Analysis.................................................179
Appendix H: Draft Benefits Realisation Plan ...................................180
xii
List of Tables
Table 4.1 Throughput (average per month in 2012)............................... 61
Table 4.2 Physiotherapy notes retrieval and filing (average per month) ... 62
Table 4.3 Phone calls (average per month in 2012) ............................... 62
Table 4.4 Documents created ............................................................. 88
Table 4.5 Data created ...................................................................... 90
Table 4.6 Information Accessed .......................................................... 91
Table 4.7 Top Ten Suggested improvements identified at the focus group
100
Table 5.1 Which processes should be improved? ..................................106
Table 5.2 Suggested Improvements not yet progressed ........................123
xiii
List of Figures
Figure 1.1 Body chart anterior and posterior view ................................... 3
Figure 2.1 Six aims for improvement outlined by the IOM ...................... 11
Figure 2.2 Principles of Lean Thinking .................................................. 19
Figure 2.3 PDSA cycle ........................................................................ 22
Figure 2.4 High-level flowchart for ischaemic heart disease patient ......... 26
Figure 2.5 Fishbone diagram .............................................................. 29
Figure 2.6 Check Sheet ...................................................................... 30
Figure 2.7 Control chart ..................................................................... 31
Figure 4.1 High level process map ....................................................... 66
Figure 4.2 Key Data Repositories ........................................................ 68
Figure 4.3 Data storage and access ..................................................... 69
Figure 4.4 Referral Management and Triage ......................................... 70
Figure 4.5 Waiting list Management and Appointment Booking ................ 72
Figure 4.6 Waiting List Reporting and Queries ....................................... 75
Figure 4.7 Patient Attendance ............................................................. 77
Figure 4.8 Registration ...................................................................... 80
Figure 4.9 Patient Non-Attendance ...................................................... 81
Figure 4.10 Discharge ........................................................................ 83
Figure 4.11 Retrieval and Filing of Physiotherapy Notes ......................... 85
Figure 4.12 Clinical Documentation and Information Access .................... 87
Figure 5.1 Venn diagram of suggested improvements from interviews and
focus group .....................................................................................111
Figure 5.2 Number of patients waiting for a rheumatology physiotherapy
appointment Jan 2012 – July 2013 .....................................................115
xiv
Figure 5.3 Number of patients waiting for an orthopaedic physiotherapy
appointment Jan 2012 – July 2013 .....................................................115
Figure 5.4 Number of weeks patients waited for a rheumatology
physiotherapy appointment Jan 2012 – July 2013 ................................116
Figure 5.5 Number of weeks patients waited for an orthopaedic
physiotherapy appointment Jan 2012 to July 2013 ..............................116
Figure 5.6 Body Chart in Cerner Millenium EPR ....................................118
Figure 5.7 Possible Future Process Map ...............................................121
Figure 5.8 Possible Future Key Repositories .........................................122
xv
Abbreviations
AHP Allied Health Professional
AHRQ Agency for Healthcare Research and Quality
ARCHI Australian Resource Centre for Healthcare Innovations
ASQ American Society for Quality
DoH&C Department of Health & Children
DNA Did Not Attend
ED Emergency Department
EHR Electronic Health Record
EMR Electronic Medical Record
EPR Electronic Patient Record
HIMSS Healthcare Information and Management Systems Society
HIQA Health Information and Quality Authority
HSE Health Service Executive
IHI Institute for Healthcare Improvement
MeSH Medical Subject Headings
NCP National Clinical Programmes
PAS Patient Administration System
SOAP Subjective, Objective, Analysis, Plan
TQM Total Quality Management
VAS Visual Analogue Scale
VMMC Virginia Mason Medical Centre
xvi
Glossary of Terms
Bottleneck
Part of the system where patient flow is obstructed, causing waits
and delays e.g. waiting for an appointment
Capacity
Resources available to do the work
Demand
All the referrals/requests coming in from all sources
Flow
The progressive, uninterrupted movement of products, information
and people through a sequence of processes
Functional bottleneck
Service that has to cope with demand from several sources e.g.
physiotherapy, radiology, pathology
Hand-offs
The number of times work is passed from one person to another
person
Kaizen Event
An improvement tool that brings together employees to examine a
problem, propose solutions, and implement changes. Kaizen events
usually take place over several days
Map of Medicine
The Map of Medicine supports the optimisation of care by providing
access to a web-based visual representation of evidence-based
patient care journeys covering 28 medical specialties and 390
pathways and clinical decision support at the point of care
xvii
New slot
An appointment slot in the outpatient booking module on the PAS
which is specifically for a new patient appointment
PhysioTools
Software used to produce personalised exercise hand-outs
Return slot
An appointment slot in the outpatient booking module on the PAS
which is specifically for a return patient appointment
Triage
The practice of sorting patients into categories of priority for
treatment
1
CHAPTER 1
INTRODUCTION
1.1 Study Context
This dissertation describes research carried out in the physiotherapy
outpatients department of a large acute teaching hospital. The research
investigated how processes could be improved in the study setting. The
research also explored the potential benefits and perceived challenges of
any suggested improvements.
The overall aim of any process improvement in the department under study
was improvement to the patient’s journey and staff morale. The focus for
this study was the orthopaedic and rheumatology patients referred to the
department. Focussing on this cohort of patients would give a
comprehensive outline of the patient journey through the department as
they go through the complete range of processes. The physiotherapists who
treat this cohort are also based solely in the main outpatients department.
Patients from other specialties such as oncology, cardiology, neurology,
women’s health and plastics are also managed as outpatients but are
treated by physiotherapists who are also based on the acute wards. Some
of these specialities would not follow the full extent of the processes e.g.
oncology patients would not go through the triaging process as they do not
go on to a waiting list as they are booked directly into an outpatient
appointment on discharge from their inpatient stay.
The department under study sees over 2,000 new orthopaedic and
rheumatology patients per annum. There are 5.5 physiotherapists and 2
clerical staff serving these patients. Of note, the clerical staff complement
has reduced from 3 in 2010 due to the Irish Health Service Executive (HSE)
early redundancy scheme at the end of 2010.
In theory, there appears to be sufficient physiotherapy capacity to prevent a
waiting list but there continues to be several weeks of waiting for patients.
2
The view of the clerical staff is that they are unable to book patients into
appointments in a timely manner due to lack of time. The clerical staff do
spend a significant amount of their working day making and receiving calls
from patients while many calls to the department are unanswered – see
baseline data in section 4.2.
The current workflow through the department is heavily dependent on
paper and a few separate information systems. The workflow can be broadly
divided into the following sections; referral management, waiting list
management, clinical documentation and discharge and/or onward referral.
All referrals, assessments, outcome measures and treatment plans are
paper based. The patient is reassessed each time they are referred as
accessing physiotherapy notes for previous attendances is difficult due to
reduced clerical capacity to retrieve them. There are manual processes for
referral and waiting list management. Referrals outward to the community
and other hospitals are paper-based via the general postal service. This
results in delays in referral onwards to community physiotherapy. An
internal audit carried out in 2010 showed an average delay from referral to
date stamp in the community of 6 days but in some cases up to 8.5 days.
This is before the patient goes on the community physiotherapy waiting list.
Due to all clinical documentation including outcome measures and protocols
being paper based there is a lack of easily accessible information. This
makes it difficult and time consuming to determine if (1) physiotherapists
are using outcome measures consistently, (2) if patient outcomes are
sufficient, (3) to carry out research and audit and so determine where
improvements are required clinically.
There are three main information systems in use; (1) the Cerner EPR
(Electronic Patient Record) which is used only for referrals to the outpatient
physiotherapy service and to look up test results and imaging, (2) the PAS
(Patient Administration System) for all patient appointment bookings and
registration of patient attendance and (3) PhysioTools which is a software
3
application used to generate paper based exercise programmes for patients
to carry out at home. Microsoft Excel is used for referral and waiting list
management. There is also some information saved in electronic format,
patient correspondence (to consultants), protocols, outcome measures and
relevant articles and presentations.
The following section gives an overview of key steps where information is
collected and accessed during a patient attendance in the outpatient
physiotherapy department under study. For further background on the
physiotherapy outpatient setting see Appendix A.
In the outpatient physiotherapy setting (following consent from the patient
for treatment) the patient receives an initial assessment from an individual
physiotherapist. All information from this initial assessment is recorded on a
standardised assessment for, which includes a body chart. Clinical
information for follow-up appointments is recorded in the form of a SOAP
note (Subjective, Objective, Assessment and Plan). The standardised
assessments and SOAP notes are paper-based.
Figure 1.1 Body chart anterior and posterior view
(Reproduced from Whitman, J., Flynn, T., Wainner R and Magle J., 2002. Orthopaedic Manual
Physical Therapy Management of the Lumbar Spine, Pelvis, and Hip Region. Fort Collins, CO:
Manipulations, Inc.)
At the initial visit the presenting complaint is recorded on a body chart.
Figure 1.1 above is a standard view of a body chart. Physiotherapists use
4
symbols to describe the location of symptoms, nature of any pain (sharp,
ache), the frequency of the pain (intermittent, constant) and whether the
pain radiates. The notations used are not currently standardised among the
physiotherapists in the department under study.
Assessment of red flags is a key part of the physiotherapist’s examination to
alert the physiotherapist to the possibility of a more serious underlying
condition. While most patients will have musculoskeletal conditions as an
explanation of their symptoms, a small number will have a more serious
condition such as malignancy. These patients need to be identified and
referred urgently to a medical specialist. Going through the list of red flags
systematically greatly reduces risk. An example of a red flag in a patient
with low back pain would be a change in bladder habit e.g. incontinence.
The physiotherapists should use an outcome measure at the initial
assessment and intermittently thereafter to determine patient progress.
Many of these outcome measures are self-reported questionnaires.
However, due to time constraints and difficulties with analysing the
resulting data they are not used consistently.
Advice and education are a very important part of the physiotherapist’s role,
and the patient will be given further educational material such as an
exercise sheet or information on their condition. These exercise sheets are
pre-printed or generated from PhysioTools. When treatment is complete the
patient is discharged back to the referring consultant and previously a
discharge summary was written to the consultant outlining the treatment
undertaken and the progress to date. This discharge summary was not in a
standardised format. Due to a shortage of clerical staff discharge letters are
no longer written.
Physiotherapists refer to the evidence base for the most relevant outcome
measures, clinical pathways and the latest evidence. This occurs outside
patient treatment times due to time constraints and issues with access to
5
this information. This information is accessed on the department’s shared
drive or via the internet.
Management reports are available from the information inputted on the PAS
and are downloaded monthly e.g. DNAs (Did Not Attends), cancellations and
number of new and return patients. However, other metrics such as waiting
time (required by the Health Service Executive (HSE)) continue to be
determined through inefficient manual processes. Manual collation of
numbers waiting and waiting times is necessary as the referral comes
through the EPR (date stamped on EPR) and the booking occurs separately
in the PAS and there is currently no link between date of referral and date
of appointment to allow for calculation of waiting time.
In summary, there are a number of issues:
Reduction in clerical capacity
Dependency on paper
Disparate IT systems
Some of the reports required locally and nationally generated
manually
Delays in patient referrals reaching the community services
Lack of standardisation in use of notations on the body chart
Lack of easy access to information to review previous attendances,
analyse outcomes and carry out research and audit
Discharge letters not sent to the referrer to complete patient journey
1.1.1 National Context
At a national level there are some key initiatives that are driving the need
to improve the processes of the patient journey and how data is collected
and reported along that journey. Three of these are outlined below; (1) the
requirement for physiotherapy departments to submit data to the HSE each
month, (2) the work of the National Clinical Programmes (NCP) and (3) the
6
Health Information and Quality Authority (HIQA) publication the “National
standards for Safer, Better, Healthcare”. It remains to be seen if the work
around “money follows the patient” (Department of Health & Children
(DoH&C), 2013) will include the money following the input provided by
physiotherapists but the drive from the HSE is certainly to keep waiting lists
low and the work of the NCP and HIQA is focussed on improving the quality
of the patient journey.
1.1.1.1 HSE CompStat
Each month physiotherapy departments nationally, submit a report of
clinical activity (including the number of patients seen, waiting times and
numbers waiting) to CompStat (formerly HealthStat2). This is the public
health services performance dashboard and is published online by the HSE.
HealthStat was devised to provide ‘reliable, timely and comprehensive
information about how our services are delivered to those who use them’
(HSE, 2011). CompStat compares the monthly performance of twenty nine
public hospitals. Actual performance is then compared with a target of the
average of the top three best performing hospitals. The aim is to have no
patient waiting for outpatient physiotherapy for more than 6 weeks. It is
therefore, imperative that the data submitted is collected accurately.
1.1.1.2 HSE National Clinical Programmes (NCP)
The objectives of the NCPs are to improve quality, improve patient care and
access and ensure value for money. The new clinical director of the NCP has
outlined that patient flow should be embedded in all NCPs and that all
programmes have a dependency on data to understand demand/capacity
issues and to measure patient outcomes. All NCP programmes are
developing clinical decision making support tools such as guidelines,
algorithms, referral templates, data sets, bundles and models of care (HSE
NCP). Physiotherapists are involved in all programmes either as therapy
2http://www.hse.ie/eng/staff/Healthstat/about/
7
leads or support to the therapy lead and the work of all programmes
impacts the care provided by physiotherapists.
1.1.1.3 Health Information and Quality Authority Standards3
The Health Information and Quality Authority (HIQA) published the ‘National
Standards for Safer Better Healthcare’ in June 2012. The standards focus on
patient-centred, effective, safe and reliable services and outline how
accurate and timely information is key to driving improvements in patient
care. The department under study will be accredited according to these
standards.
1.2 Research Questions
This research will attempt to answer the following questions:
Main Question (MQ):
How can processes be improved in a physiotherapy outpatient
setting?
Sub questions (SQs):
What process improvement methodology is appropriate to apply in
the physiotherapy outpatient setting? (SQ1)
Which processes should be improved? (SQ2)
How should processes be improved? (SQ3)
What are the potential benefits of any suggested improvements?
(SQ4)
What are the perceived challenges of any suggested improvements?
(SQ5)
3http://www.hiqa.ie/standards/health/safer-better-healthcare
8
1.3 Motivation for the Research
The main motivation for this research is to add to the limited body of
research in this area. Despite the vast and ever expanding body of literature
on process improvement and electronic records, physiotherapy specific
literature makes up a very small percentage. Use of a specific process
improvement methodology will allow for the structured identification of
possible improvements, where paper could be reduced, inefficiencies could
be eliminated and information technology could add value.
Some of the issues with the current processes that the researcher was
aware of before commencing the research are summarised at the end of
section 1.1, all are motivators for the research.
Local motivation factors include the announcement that the proposed new
children’s hospital will be based on the site. This is significant as it will
involve the knocking down of the physiotherapy building within 12 months.
It would be advantageous to move to a new location with inefficiencies
ironed out and new ways of working standardised in so far as possible.
In addition, one of the eight areas of focus of the organisation’s corporate
strategy is paperless systems and to move to a higher level on the HIMSS
(Healthcare Information and Management Systems Society) European EHR
Adoption Model4.
1.4 Overview of the Research
A literature review was carried out to gain a clear understanding of process
improvement methodologies prevalent in healthcare and the tools
commonly used. Process improvement based on the principles of Lean
Thinking was selected by the researcher as the best fit for the case under
study. This methodology was then applied in three stages of process
mapping through observation, semi-structured interviews with key
physiotherapy informants and a staff focus group. This methodology
4 http://www.himssanalytics.eu/emr.asp
9
assisted in identifying how processes could be improved in the department.
The use of data and staff engagement were noted as key building blocks.
1.5 Overview of the Dissertation
This chapter presented the background to the research, the research
questions, motivation for the research and an outline of the dissertation.
Chapter 2 presents the literature review. The literature review addresses
the area of process improvement, methods and tools used in healthcare,
case studies in healthcare, process improvement and information
technology, process improvement and information technology in
physiotherapy.
Chapter 3 presents the research methodology. The literature review and
collection of baseline data was followed by the application of the process
improvement methodology; process mapping, interviews with key
informants and the focus group.
Chapter 4 presents the quantitative data from the process mapping stage
(stage 1) outlining how the data was collected and the time spent in
observation. The process maps are presented in this chapter. This chapter
also presents the qualitative data from the interviews, and focus group
(stages 2 and 3).
Chapter 5 presents an analysis of the data in chapter 4 and a discussion of
the findings and how the research questions have been answered.
Chapter 6 presents the study limitations, recommendations for future work
and the conclusion.
10
CHAPTER 2
LITERATURE REVIEW
2.1 Introduction
This chapter gives an overview of process improvement in healthcare.
Prevalent improvement methodologies are outlined along with an
introduction to the importance of measurement and some tools used. The
importance of data to highlight priorities for improvement and to determine
if any change results in improvement is illustrated.
Some case studies and benefits realised are outlined followed by a summary
of information technology (IT) used to drive improvement in the
physiotherapy setting. Some challenges to improvement are then
highlighted and the importance of staff engagement and change
management to assist in overcoming these challenges is emphasised.
Of relevance to this research is the emphasis in the literature on the
importance of reviewing processes, involving staff and using data to
determine the focus of improvement and to highlight if any change is indeed
an improvement. The case studies also give ideas for improvement and the
benefits realised. Regarding the introduction of IT for process improvement
the literature acknowledges the role of IT in the simplification,
standardisation and ultimately in sustainability of improvement (Hughes,
2008; Bell, 2013).
Information technology in healthcare is viewed by many as a way to reduce
costs, improve quality and safety and optimize operational efficiencies
(Institute of Medicine (IOM), 1999). However, others call for these claims to
be further substantiated (Himmelstein, Wright and Woodlander, 2009;
Black, et al., 2011).
It is acknowledged that many of the processes in healthcare can be
inefficient and complicated. Therefore, the introduction of IT without first
improving processes could result in doing the same inefficient, complicated
11
activities electronically. The allocation of current limited resources to IT
without first tackling inefficient healthcare processes will be unlikely to
generate benefits. Therefore, the need to simplify and eliminate wasteful
activities in hospital processes should be a prerequisite to implementing any
IT system. In fact, Trinity Health, a large U.S. multi-hospital healthcare
organisation, attributes much of its successful implementation of an
organisation-wide Electronic Health Record (EHR) to carrying out process
improvement initiatives prior to implementation (Brokel and Harrison,
2009).
Before looking at “process” we need to look at “quality” in health care.
Quality is a complex concept. The IOM identified six specific aims for
improvement in its report “Crossing the Quality Chasm”, 2001 (IOM, 2001;
Berwick, 2002). The six aims are depicted in Figure 2.1.
Figure 2.1 Six aims for improvement outlined by the IOM
(Institute of Medicine, 2001. Crossing the Quality Chasm: A New Health System for the 21st
Century.Washington, DC: National Academies Press)
More than 40 years ago, Donabedian (1966) proposed measuring the
quality of health care by the observation of structure, process, and
outcome. Structure measures assess the accessibility, availability, and
quality of resources; having the right things. Process measures assess the
delivery of health care by all providers; doing the right things right.
12
Outcome measures indicate the final result of health; having the right
things happen.
Process improvement, particularly in the name of quality, has been around
for a long time. Back in 1950 W. Edwards Deming spoke to Japanese
business leaders, outlining a roadmap for total quality management (TQM).
Deming outlined how most quality issues are caused by process, policy and
procedure issues rather than by people. A more recent advocate of process
improvement, Spear (2011) a senior fellow at the Institute for Healthcare
Improvement (IHI) concurs outlining that inadequately designed and
operated systems of care delivery are the cause of many quality issues.
Batalden (2006) also emphasises that poorly designed systems lend
themselves to inefficiency and poor quality.
“Every system is perfectly designed to get the results that it gets”
Paul Batalden, 2006, p. 32
The IOM report (1999) “To Err Is Human” also outlined how the majority of
errors in healthcare are the result of faulty systems and processes, not
individuals. This report also suggests that IT must play a central role in the
redesign of healthcare if a substantial improvement in quality is to be
achieved.
2.1.1 Literature Search Strategy
An initial requirement in the research process is a review of relevant
literature (Creswell, 2009). Some of the MeSH terms that were used for
this literature review included process improvement AND physiotherapy,
quality improvement AND physiotherapy, Lean Thinking AND physiotherapy,
electronic patient record AND physiotherapy, electronic documentation AND
physiotherapy, information technology AND physiotherapy, computer use
AND physiotherapy, process improvement AND healthcare and Lean
Thinking AND healthcare. For each search using “physiotherapy” a duplicate
search was also conducted using “physical therapy” as both titles are used
interchangeably.
13
The literature was searched using the electronic database Pubmed initially
followed by, ProQuest Nursing and Allied Health Source database, the BMJ
group database and others that specific journal articles led the researcher
to such as Science Direct, SpringerLink, Wiley Library, JSTOR and Academic
Search Complete.
While there is a sufficient number of articles and grey literature published
on the topics of process improvement in healthcare and Lean Thinking in
healthcare no articles were found that described process improvement
methodologies in physiotherapy. A general search was carried out to seek
out presentations or other source material related to the topic of
physiotherapy and process improvement with limited success. Therefore,
the reader will note there is reference made to health service reports and
blogs in the literature review (section 2.8).
The references of all key articles found in the initial stages were reviewed
for further relevant articles and specific leads pursued (snowballing). Alerts
were set up from the databases outlined above.
The search strategy for the literature review was a challenge. There was
limited literature on the subject of process improvement in
physiotherapy/physical therapy. The quality improvement literature is
extensive. Lean Thinking principles have been adapted to local contexts and
are applied in many settings under various guises, for example, VMPS
(Virginia Mason Production System), BICS (Bolton Improving Care System)
and Redesigning Care Programme in Australia.
This chapter will now introduce process improvement in health care,
prevalent methodologies, measurement and tools, outline some interesting
case studies and finally take a brief look at some challenges to process
improvement.
2.2 Process Improvement in Healthcare
Many countries have national healthcare quality improvement agencies
which are highlighting the importance of using process improvement
14
methodologies; the Institute of Healthcare Improvement (IHI) in the US,
the NHS Institute for Innovation in the UK, the Dutch Institute for
Healthcare Improvement (CBO) and the Australian Council for Safety and
Quality in Healthcare (Locock, 2003 (a)).
2.2.1 What is Process Improvement in Healthcare?
In healthcare, a process is a set of steps, each of which must be
accomplished properly in the proper sequence at the proper time to create
value for the customer (patient and/or staff). So invariably in order to look
at improving what the organization does, the focus must be on reviewing
and improving the process (Batalden, 2006; Victorian government report on
streaming care, 2008; Holden, 2011). Batalden (2006) outlines that trying
to change things without first understanding how things are working won’t
lead to sustainable change.
The activities that make up a process are not equal. Some activities add
value to a process and other activities fail to add value. Therefore, one way
to think about process improvement is to think in terms of reducing non-
value added activities. To understand the concepts of value-added and non-
value added processes (waste) it is important to look in more detail at
process improvement based on the principles of Lean Thinking. This will be
discussed further in section 2.3.1.
Once it is understood what processes exist in a healthcare environment
options for improvement of processes can be explored. This definition of
improvement
“An improvement is anything that brings about a measurable benefit
against a stated aim”
(NHS Institute for Innovation and Improvement Leaders Guide 1.1, 2005,
p.40)
emphasises the importance of defining aims prior to making any changes
and of using measurement to determine if a change is indeed an
15
improvement. Measurement to define priorities and determine if a change is
an improvement will be explored further in section 2.4.
An important aspect of improving processes is that it is not about cutting
people. It’s about cutting waste and inefficiency so people can carry out
their work more efficiently (Ben-Tovim, et al., 2008). Process improvement
gives staff clear ways of working and so allows them greater job satisfaction
as they are able to get on with their job without process distractions. It also
aims to ensure patients get faster and more predictable treatment
(Australian Resource Centre for Healthcare Innovations (ARCHI))5.
Some suggestions for improvement in healthcare include:
Eliminating duplication and redundant processes
Reducing time taken to complete tasks
The introduction of information technology
(NHS Institute for Innovation, 2007; Bolton Improving Care System (BICS),
2007; Campbell, 2009; Page, 2010).
Simplification and standardisation are key to sustainability of any
improvement (Ben-Tovim, et al., 2008). Once the most simple, effective
and efficient way of undertaking a process has been developed it can
become standard work. Spear (2005) also highlights the importance of
reducing ambiguity and work arounds by standardising processes and the
time taken to carry out each step in the process. McGrath, et al. (2008) also
highlight that standard processes are robust, less prone to error and are
easy to teach to new staff. However, Mazzocato, et al. (2012) caution
against over standardisation as staff can begin to find their work
monotonous.
5 http://www.archi.net.au/
16
In section 2.6 some case studies outline further examples but first we will
look at levers for process improvement followed by the process
improvement methodologies and tools prevalent in health care.
2.2.2 Levers for Process Improvement in Healthcare
The main lever for process improvement in health care should always be the
patient as the customer. The Agency for Healthcare Research and Quality
(AHRQ)6 highlights that rising demands in healthcare, increasing costs,
workforce shortages and the requirement for quality outcomes have all led
healthcare organisations to look for opportunities through process
improvement.
According to NHS Institute for Innovation (2005) and Fillingham (2008) the
main levers for process improvement are:
• To improve the journey for the patient leading to better outcomes
and experiences for patients
• To increase staff morale
• To improve overall performance in terms of efficiency, quality and
safety
• To improve the flow of information
• To reduce waiting lists
• To avoid mistakes
• To develop a business case
• To understand the culture we work in
The IHI also emphasises patient-centred care as a key lever for process
improvement and other authors outline how the patient as the customer
must remain as the central focus and that the patient’s experience should
be improved at every opportunity (Philips and Hughes, 2008).
6http://www.ahrq.gov/qual/toolkit/toolkit3.htm
17
In Virginia Mason Medical Centre (VMMC), Kaplan (Albright, 2008) outlines
that the board challenged staff to take a closer look at their processes to
make sure everything they did was for the benefit of the patient.
Mazzocato, et al. (2012) outline a similar directive from the hospital board
at Lindgren’s children’s hospital in Sweden for the initiation of process
improvement.
Other levers include:
A crisis (the Emergency Department in the newspaper due to long
waits), The need to transform the organisation
A general desire to improve processes
A need to demonstrate improved operational or financial results
A need to exploit strategic events such as an information technology
implementation, integration of care and building a new facility
(Fine, Golden, Hannam, and Morra, 2009; The Philips Healthcare white
paper, 2009).
Overall the requirement to do more with less highlights an opportunity to
step back and determine if process steps actually need to be done at all
(Locock, 2003 (b)).
2.3 Methodologies in Process Improvement in Healthcare
As outlined, quality issues are generally a result of system or process
failures. Like any other business, healthcare requires a framework built
upon best practices in process improvement and innovation (Bell, 2006;
Hughes, 2008).
In recent years healthcare organisations are turning to quality improvement
methodologies with origins in the manufacturing world such as Lean
Thinking, Six Sigma, Business Process Re-engineering, Theory of
Constraints, Queuing and TQM (total quality management)/CQI (continuous
quality improvement) (Albright, 2008; Murray, 2009). Healthcare, like
manufacturing, is a complex system with multiple processes that must be
18
aligned to deliver optimal services of high quality at reasonable cost.
Another methodology outlined in the literature which does not have its
origins in manufacturing is the IHI’s Plan-Do-Study-Act (PDSA) cycle.
The use of methodologies and tools for process improvement in healthcare
has expanded in recent years and some can be quite complex to understand
and apply. However, fundamental concepts can be applied to improve
processes and a basic understanding of methodologies and tools is a
starting point for any process improvement project. According to Locock
(2003 (b)) much of it is common sense and accessible to all.
In healthcare, models are not always clearly outlined and in fact healthcare
settings often pull on a range of methodologies and apply them in a
piecemeal fashion (Powell, Rushmer and Davies, 2009).
However, all of the process improvement methodologies outlined involve
mapping out the current workflow, establishing baseline data (how long
process takes, cost), validating that the workflow accurately reflects the
existing processes, applying improvement techniques and use of
improvement tools, implementing change and driving continuous
improvement (ARCHI, NHS Institute for Innovation, 2005).
There follows an outline of the three methodologies most commonly used in
healthcare. There are others in the literature and the reader is referred to
the work of Murray (2009) and the Powell, Rushmer and Davies (2009) NHS
confederation report for further review.
2.3.1 Lean Thinking
Lean thinking, as the name implies is a mind-set. Macleod, Bell, Dean and
Baker (2008) suggest that Lean Thinking is becoming a critical tool for
healthcare. Lean Thinking was developed by Toyota in the 1950s and its
application in healthcare began in the early 2000s (Young and McClean,
2009). Lean Thinking in healthcare is largely based on the work of Deming
at the IHI. It emphasises streamlining processes and standardisation to
provide what the internal (staff) and external (patient) customer wants with
19
minimal waste (Dickson, et al., 2009). This methodology uses a range of
tools to identify blockages in process flow and then looks at removing
unnecessary steps in the process. It is a different way of looking at
healthcare, moving away from the work of specific clinicians or body
systems towards processes (Ben-Tovim, et al., 2008).
There are five principles of Lean Thinking (see figure 2.2) (Ben-Tovim,
Dougherty, O’Connell and McGrath, 2008; Campbell, 2009):
Identifying value. This involves identifying anything that adds value
to the customer
Mapping the value stream. This involves mapping the complete set of
process steps
Making value flow. This involves eliminating non-value added
activities and simplifying and standardising the remaining steps that
do add value. This also involves the elimination of batching and
queuing. Ultimately for the patient this means giving them just what
they need when they need it without waiting
Establishing pull. This allows for work to be pulled to the next step
(rather than pushed, for example, on to a waiting list)
Seeking perfection. This requires continuous improvement and the
sustaining of any improvements made
Figure 2.2 Principles of Lean Thinking
(Lean Enterprise Institute, Principles of Lean Available at:
http://www.lean.org/whatslean/principles.cfm)
20
To identify non-value added activities Lean Thinking assigns non-value
added activities (waste) into seven categories:
1. Overproduction – incompatible IT systems or dual paper and IT-based
systems can lead to duplication of data entry
2. Waiting – time spent where resources are idle or time spent waiting for a
service
3. Transportation – moving resources (paper or staff or equipment) from
one location to another which introduces delay and inefficiency
4. Nonessential activity – performing an activity that makes no contribution
to the service provided to the customer
5. Inventory – holding resources until they can be used
6. Variation – changes or deviations from the expected outcome or the
expected standard
7. Defects – errors produced during the process
The idea in Lean Thinking is to squeeze non value activities out of a process
(Mazzocato, et al., 2012). Fine, Golden, Hannam and Morra (2009) give
examples of waste as test results that are never read, staff walking miles
daily and repeating tests as forms of waste. Fillingham (2008) adds staff
searching for equipment, staff recording information many times and staff
not having important information to hand when needed.
In summary, Lean Thinking views any non-value added activity as waste,
focuses on process and the tools used are all related to visualising where
there is waste. Value is always defined from the customer’s viewpoint
(patients and staff in healthcare). Data is key to the identification and
prioritisation of improvement initiatives (see section 2.4) and staff
involvement is crucial for success and sustainability. Lean Thinking as a
methodology is often selected where an organisation values a visual
improvement along with positive changes in speed and efficiency (ARCHI).
21
A review of projects using Lean Thinking by Hughes (2008) reported that
health care organizations improved patient safety and the quality of health
care by systematically defining the problem; setting goals, removing
workarounds and clarifying responsibilities. Team members in the
improvement projects developed action plans that improved, simplified, and
redesigned work processes. In contrast to this Holden (2011) found in his
review of Lean Thinking in emergency departments studies did not report
on patient safety outcomes or on quality aspects. Research on Lean
Thinking is limited with studies lacking clear research designs, limited
metrics, a variation in terminology/definitions, tools and methods used and
there is a knowledge gap regarding how and why Lean Thinking may work
in healthcare making it difficult to determine which aspects work best
(Young and McClean, 2009; Mazzocato, et al., 2012). In 2010, Mazzocato,
et al., outlined that 33 articles they reviewed all reported positive results
suggesting a bias towards reporting of successful implementations. In
summary, there is scope for methodological development (Young and
McClean, 2008). Further challenges are outlined in section 2.5.
2.3.2 Six Sigma
Six Sigma is the newest of the methodologies prevalent in healthcare. It
originated in Motorola in the mid-1980s and has been used in
manufacturing since then but in healthcare only in the last 15 years.
Six Sigma uses a five-phased structured approach and is a very rigorous
statistical measurement methodology. The five-phased approach is known
as the define, measure, analyse, improve, and control (DMAIC) approach.
Statistical tools, for example, statistical process control charts, are used to
identify variation in processes. Six Sigma recognises that variability can
prevent the delivery of a consistent quality service (Eitel, et al., 2010). This
22
method requires statistical expertise and reliable data collection and usually
requires intensive technical training (ARCHI7; NHS8; IHI9).
Albright (2008) highlights that Lean Thinking and Six Sigma share some
similarities. However, Six Sigma is a problem-solving methodology focused
primarily on reducing process variation while lean focuses more on
improving process flow. Lean Thinking also allows for more holistic decisions
to be made about opportunities for process improvement with the emphasis
on involvement of staff and observation of the workflow in situ whereas Six
Sigma tends to look at disembodied facts and statistics. Six Sigma as a
methodology is often selected where an organisation values analytics and
precision (ARCHI).
2.3.3 Plan-Do-Study-Act (PDSA)
Figure 2.3 PDSA cycle
(Langley, G.J., Moen, R., Nolan, K.M., Nolan, T.W., Norman, C.L. and Provost,
L.P., 2009. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.
2nded. San Francisco: Jossey-Bass)
The Plan-Do-Study-Act (PDSA) cycle depicted in figure 2.3 above has been
widely used by the IHI for rapid improvement in healthcare. One of the
unique features of this model is the cyclical nature of assessing change
7 http://www.archi.net.au/
8http://www.institute.nhs.uk/
9 http://www.ihi.org/Pages/default.aspx
23
through small and frequent PDSA cycles before changes are made system
wide. In this way this methodology turns ideas into action and connects
action to learning (Varkey, Reller and Reser, 2007).
Langley, et al. (2009) propose a model for improvement which poses three
questions before using the PDSA cycles: (1) what are we trying to
accomplish? (Aim) (2) how will we know that a change is an improvement?
(Measures) (3) what change can we make that will result in improvement?
(Change). The PDSA cycle starts by determining the problem, what changes
can be made, a plan, who should be involved and what should be measured
to understand the impact. The change is implemented and data and
information are collected. Results from the implementation study are
assessed and interpreted by reviewing key measurements that indicate
success or failure. Finally, action is taken on the results by implementing
the change or beginning the process again. PDSA cycles allow low risk tests
of change based on proposals of frontline staff and so encourages staff
engagement. As outlined by Powell, Rushmer and Davies (2009) there is
only limited evidence in the peer-reviewed literature of changes in
outcomes from this approach.
The next section outlines the importance of data and measurement in
process improvement.
2.4 Measurement in Process Improvement in Healthcare
The literature outlines some of the measures used to monitor the impact of
any process improvement initiative. These include counting the number of
steps in the process, the time to carry out each step in the process, the
waiting time at each step, the total cycle time, throughput, capacity and
demand, the number of errors, staff numbers involved and customer
satisfaction.
One of the universal principles for a sustained approach to improving a
process is to measure the process. Data helps to identify problems,
prioritise problems and determine if improvement has occurred (Chyna,
24
2002). In Lean Thinking terms data can “push” improvement by identifying
problems and “pull” improvement by identifying opportunities (Victorian
Government report on using data for quality improvement, 2008). Once the
process is measured there is an opportunity to get control over it. McGrath,
et al. (2008) highlight that data must be used to determine if a change is an
improvement and so any solution can become more evidence based. Some
authors also emphasise that data used for measurement needs to be
simple, clearly visible and available in real time (McGrath, et al., 2008;
Eitel, et al., 2010).
The establishment of a baseline position for measuring and communicating
the improvements can also be an exciting and motivating factor for teams
(Fillingham 2008; NHS Institute for Innovation, 2005; ARCHI). However,
Holden (2011) in his review of Lean Thinking in 15 EDs (Emergency
Departments) points out that pre and post metrics were often not measured
and no numeric data was given to support the reported improvements.
A weakness in the literature on improvement methods is that there is
minimal discussion on the costs of implementation and while many
initiatives state a reduction in cost through increased efficiency as one of
their objectives there is a lack of evidence to suggest reductions have
occurred (Powell, Rushmer and Davies, 2009). However, it is acknowledged
that measuring and analysing cost savings from these initiatives presents
complex challenges (Brennan, Sampson and Deverill, 2005).
2.5 Tools used to Understand and Improve Processes
This section outlines some of the tools used in process improvement. Some
tools are used to collect data on processes in order to visual where issues
are occurring, for example a process map; others are used to further
explore problems to examine their cause and effect, for example a fishbone
diagram; and others work with numbers to monitor progress.
25
“If you can’t describe what you’re doing as a process, you don’t know what
you’re doing,”
The father of the quality revolution, W. Edwards Deming 1900-1993
2.5.1 Process Mapping
Process Maps are a visual representation of the steps that make up a
process and are a key first step when using process improvement
methodologies. They can describe process steps, timing, and frequencies at
the highest level and work downward. High level process maps give an
overview of the process. Lower level maps help analyse the process in
greater detail and can assist in highlighting priority areas for improvement
(ARCHI; IHI, 2004; NHS, 2005). Of note, attention to detail in the lower
level maps is important to determine how best to integrate healthcare IT
into workflow (Crandall, et al., 2007). Attention to detail at bottlenecks is
also important (NHS Scotland Quality Improvement Hub, 2008). It is
important to define the beginning and end (the scope). As process mapping
is a key step in process improvement it is outlined here in more detail than
the other tools. Figure 2.4 below outlines a high-level process map for an
ischaemic heart disease patient. The diamonds in the map are decision
points where the patient journey can take one of two paths depending on
the decision-making process.
26
Figure 2.4 High-level flowchart for ischaemic heart disease patient
(Institute for Healthcare Improvement (IHI), Process Improvement Tools, Flowcharts, 2004. [pdf]
http://nnphi.org/CMSuploads/Flowcharts%20Guide.pdf)
There is little guidance in the literature regarding the most effective type of
process map to use (Colligan, Anderson, Potts and Berman, 2010). Patient
orientated approaches to process mapping put the patient at the centre and
remind staff of why process improvement is needed. This method may be
preferable to more clinician orientated workflow with each clinician depicted
in parallel “doing” things to the patient. Ozkaynak, et al. (2013) outline how
clinician orientated workflow, unlike patient orientated, can lose sight of the
cooperative work that prevails in healthcare and that a more patient
orientated approach can help characterise the gap between clinical and non-
clinical practices and inform the IT that can bridge the gap. However, it
should be emphasised that a review of clinical workflow and integration of
any process improvement (including IT) into such workflow is crucial to get
buy-in from staff (Kawamoto, Houlihan, Balas and Lobach, 2005; Bowens,
Frye and Jones, 2010). Therefore, in many cases more than one type of
map may be appropriate.
Process mapping is used to depict the flow of steps within a process. In
order to map a process the activities need to be understood, what triggers
27
these activities (inputs), who is involved, the sequential steps, and the
outputs associated with the steps (Fine, Golden, Hannam and Morra, 2009).
Where possible, it is also recommended that time consumed at each step or
at some key steps is documented (Holden, 2011). The Victorian
Government report on Process Mapping (2007) recommends keeping
process maps simple by not using complex symbols and shapes that are not
easily understood.
Once completed the process map can be used to answer certain critical
questions:
1. Can we eliminate or reduce certain activities?
2. Can we complete the process in less time by changing the process?
3. Can we improve how we meet customer requirements by changing the
process?
The importance of process mapping by on the ground observation is
emphasised by Bell (2006). This is a Lean Thinking concept of “Gemba” or
“going where the action is”.
Summarised below are some of the benefits of process mapping
• Once workflow is mapped opportunities for improvement can be
identified
• Mapping assists in the understanding of all the processes involved in
the patient journey. Sometimes staff are seeing the complete patient
journey for the first time and this increases their understanding of
the journey and its complexity. Mapping makes all stages visible to
all involved and engages staff in owning any problems that emerge.
In short, mapping can generate permission to change from all
involved (Victorian Government report on Process Mapping, 2007;
Ben-Tovim, Dougherty, O'Connell, and McGrath, 2008; Eitel, et al.,
2010).
28
• Mapping promotes collaboration and improved communication
between staff members. It provides an opportunity to bring people
together and boosts team morale. Mapping has also been shown to
really assist in understanding capacity and demand problems (NHS,
2005).
In Lean Thinking process maps called value stream maps can be used to
take process mapping a step further by establishing the steps but also
outlining which steps do and don’t add value (waste).
2.5.2 Focus Groups and Interviews
Focus groups and interviews are common methods of gaining qualitative
data to guide improvement initiatives. They can provide valuable input in
terms of diagnosing any issues and gaining an understanding of the
perspectives of various stakeholders in a short amount of time. They are
also useful for identifying and exploring challenges (Victorian Government
report on using data for quality improvement, 2008).
Focus groups are important for ideas generation. One of the key elements
of any improvement work is getting staff views on what could be improved
(section 2.9). Appropriate representation of stakeholders is also an
important consideration and Bell (2012) recommends IT department
involvement (section 2.7). It is important to be clear about goals, roles and
what will happen, to stick to the start and finish time and allow each person
present to have their views heard. If there are dominant people in the
group, a method whereby each person has an opportunity to write
down/express their views is preferable. The NHS Leaders Guide on “Working
with Groups” gives some useful ideas on how to conduct these groups. Once
all ideas are outlined by participants ideas can be prioritised (NHS, 2005).
Interviews are used to garner more in-depth information from a limited
number of experts. These experts can give their valuable insight and
recommend solutions. Interviews tend to be more objective as those
interviewed do not have any affiliation with the organisation and can lead to
29
more frank discussions whereas the larger number in a focus group can
limit or bias discussion. The interviewees can help direct towards similar
work or other experts. Interviews are commonly guided by a script and can
be face to face or on the telephone (NHS, 2005; Victorian Government
report on using data for quality improvement, 2008).
2.5.3 Fishbone Diagrams
Ishikawa, Fishbone, or Cause and Effect Diagrams visually represent the
causes of a problem/effect and help determine the ultimate source of the
problem (IHI; NHS).
Figure 2.5 Fishbone diagram
(NHS Institute for Innovation and Improvement Quality and Service Improvement Tools)
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement
_tools/cause_and_effect.html)
This tool invented by Ishikawa is called a “fishbone” diagram because of its
appearance. The cause-and-effect diagram can be used for further analysis
to determine why a particular problem/effect occurs. Once a problem/effect
is identified as a priority for improvement all causes are listed by the team.
The causes can then be listed in order of priority as a focus for
improvement work. In Figure 2.5 the causes are broken down in 4 sections;
environment, methods, equipment and people. Causes in terms of methods
outlined include lack of automation, too much paperwork and the process
taking too long.
30
2.5.4 Data Check Sheets
Data check sheets, or recording tables are used to collect observational data
which can be analysed to identify opportunities for improvement. They are
usually used to collect data repeatedly at the same location or by the same
person (ASQ, 2004; Victorian Government report on using data for quality
improvement, 2008). Figure 2.6 below shows a check sheet used to collect
data on telephone interruptions. The tick marks were added as data was
collected over several weeks. These interrupt the staff workflow and an
analysis would determine if they are valued added or non-value added.
Figure 2.6 Check Sheet
(To collect data on telephone interruptions from the American Society for Quality (ASQ)
http://asq.org/learn-about-quality/data-collection-analysis-tools/overview/check-sheet.html)
2.5.5 Statistical Control Chart
The control chart is a type of statistical process control tool. Process
performance is plotted over time against upper (UCL) and lower control
limits (LCL). This chart helps to readily identify process variations over time.
Control charts are used both during and after process improvement
implementations. Variations evidenced on a control chart can highlight a
focus for process improvement and once improvements have been
implemented control charts can be used to ensure that processes are
maintained within pre-determined control limits (Varkey, Reller and Resar,
2007).
31
Figure 2.7 Control chart
(Control chart of falls per 1,000 patient days from Quality Digest
http://www.qualitydigest.com/june08/articles/03_article.shtml)
Figure 2.7 outlines the number of falls per 1,000 patient days. The UCL is
set at 4.5 and if the control chart shows a peek above this UCL further
investigation is carried out and the necessary improvements implemented.
2.5.6 Summary
To achieve the best results in process improvement the literature
recommends the following strategies (Locock, 2003 (b); Hughes 2008;
Holden, 2011):
Draw a process map to understand the process flow
Document the time consumed at each or key steps
Use check sheets if observing the process to collect repetitive data
Analyse the process map and identify which problems to focus on
Develop a cause-effect diagram if the cause of problems is not easily
identified
Prioritise improvement opportunities
32
Following the introduction of a process improvement initiative a
control chart can be used to ensure that the process is staying within
process control limits
Some improvement opportunities will be easily identified once the process
map is drawn and can be implemented immediately. This is often referred
to as “Just do it!” in Lean Thinking.
2.6 Case Studies
Some healthcare organisations are using process improvement
methodologies to target improvements in a wide range of departments both
clinical and administrative: laboratories, emergency departments, wards
and stock are the areas most commonly targeted. Improvements in
emergency departments are frequently cited in the literature (Dickson, et
al., 2009; Mazzocato, et al., 2010; Holden, 2011). Process improvement
methodologies are also applied to achieve improvements in such areas as
diagnostics, patient records, operating rooms, outpatient services,
pharmacy, quality assurance, IT and accounts. Middleton, et al. (2009)
outlines clearly the reduced workload, time spent and cost of improving
processes through the introduction of IT in a radiotherapy department.
Many of these sites use process improvement methodologies based on the
principles of Lean Thinking.
From a review of improvement work by thousands of clinical teams across
the UK in 2004, the NHS Institute for Innovation (2005) outlined the 10
improvements with the highest impact and benefit. They outline that the
work to match capacity and demand and reduce variation particularly at
bottlenecks has led to some of the most exciting improvements in
healthcare processes. The 10 high impact improvements are outlined below.
1. Day surgery being the norm
2. Improving flow through access to diagnostic tests
3. Managing variation in patient discharge thereby reducing length of
stay
33
4. Managing variation in the patient admission process
5. Avoiding unnecessary follow-ups and ensuring any follow-ups occur in
the right care setting
6. Care bundle packages to increase reliability of performing therapeutic
interventions
7. A systematic approach to care for people with long term conditions
8. Improve access by reducing the number of queues
9. Optimise patient flow through service bottlenecks using process
templates
10. Redesign extended roles in line with efficient pathways
However, success depends on what is done correctly at the outset of any
improvement effort. Identifying opportunities through process mapping and
measures to be used are essential pre-requisites for the delivery of benefit
(Fillingham, 2008).
Some specific case studies of process improvement now follow. The
majority have used a methodology based on the principles of Lean Thinking
and they were chosen as they are leaders in the field and/or have
introduced process improvements that could be applicable to the study
setting.
Gary Kaplan (Kenney, 2011), CEO of Virginia Mason Medical Centre (VMMC)
in the USA, emphasises that at VMMC “Lean” is not just an improvement
system; it is a culture. VMMC was the first health centre to integrate the
Toyota Manufacturing (Lean) philosophy back in 2000 (Holden, 2011;
Kenney, 2011; Mazzocato, et al., 2012). Process improvements include a
patient alert system, nurses using computers on wheels (COWs) for change
of shift handovers to take them away from the nurses’ station and be more
visible to patients which also reduced the number of steps they took daily
by up to 90%. They also introduced contemporaneous documentation and
order entry by portable wireless computer and computer access in all
34
outpatient rooms. All of these improvements were achieved through the
introduction of IT.
The VMMC outline benefits of improvements in terms of reduced costs,
decreased time to report test results and a decrease in the amount of
walking for staff. Now patients get to spend more time with healthcare
providers, patients have less delays, more timely results and treatments,
staff have less duplication and when best practices are introduced they
become the standard (Womack, et al., 2005; Kaplan and Patterson 2008;
Kenney, 2011).
Intermountain healthcare is recognised internationally as a pioneer in both
quality improvement and health information technology. Intermountain uses
a system called HELP2 which provides clinical decision support to clinicians
through automated clinical tools, gives a longitudinal view of patient records
and collects aggregate data for use in quality improvement. While similar
paper-based tools (protocols, infection control tools, guidelines and
summary worksheets) have been used at other organisations, the use of
more than a few of these tools has been shown to require information
technology (Intermountain briefing report, 2013; Thompson, Classen and
Haug, 2007).
At the Flinders Medical Centre in Australia (Ben-Tovim, et al., 2008) the
redesign of care (as it is known there) using Lean Thinking began in 2003.
They concentrated on improving the processes for the Emergency
Department (ED) and medical and surgical patients, standardisation of work
and sustainability of improvements. By rearranging the order in which
patients were seen during ward rounds patients ready for discharge were
seen first and this meant discharge summaries were completed more
efficiently and the authors reported that over 80% were completed within
24hours. The Australian experience also highlights the importance of
suitable IT systems as a key enabler of process improvement.
35
Thedacare in the USA, the nation’s “most wired” hospital10, also uses Lean
Thinking principles. Improvements ensured all patients were visited by the
multidisciplinary team (MDT) on admission and a care plan devised which
was documented in the electronic medical record (EMR) so that it could be
accessed by all providers and orders could be generated. They had reduced
errors, length of stay and greatly improved customer satisfaction (Womack
et al., 2005; Thoussaint, 2007)11.
Bolton Improving Care System (BICS), which is a Lean Thinking approach
has been implemented throughout Bolton hospital. This led to a reduction in
the steps for routine bloods from 309 to 57 steps (70%) and fewer staff
were required to carry out these tasks and there was a 90% reduction in
the time taken (Jones and Mitchell, 2006).
In Canada, Lean Thinking began in 2005 within 5 hospitals initially. They
reported reduced ED wait times, reduced length of stay, improved operating
room usage, increased radiology procedures per time period and better
infection control measures as a result (Fine, Golden, Hannam and Morra,
2009).
In Sweden, Lean Thinking led to the introduction of a data board in a
paediatric ED which was used to highlight if the flow of patients was slowing
down with patient names turning red if target timeframes were surpassed
(Mazzocato, et al., 2012).
Some primary care practices in California are adopting touchscreen tablets,
kiosks or patient portals that automate the registration process which
results in shorter waiting times, a reduction in errors and lower staff costs
(Rhoads and Drazen, 2009). At Vanguard urologic institute in Houston a
self-service patient check-in kiosk has enabled patients to enter their
personal health information and consent to treatment (Webster, 2011).
10http://www.thedacare.org/News%20and%20Events/Company%20News/ThedaCare%20Ag
ain%20Ranks%20Among%20Most%20Wired.aspx
11 http://www.innovations.ahrq.gov/content.aspx?id=3355
36
This initiative has reduced the number of errors and lost charts and
provides an opportunity to assess the patient experience. Patients at
Vanguard wait an average of 2.44 minutes only (the national average wait
being 21.3 minutes (ASQ)).
“It lessens the work that I wouldn’t consider high value and the patients can
do it better. I think job satisfaction is higher when you are doing more
interesting work”
Kevin Slawin, MD, Vanguard Urologic Institute p. 2
In a review of Lean Thinking in EDs Holden (2011) looked at 15 EDs in the
USA, Australia and Canada. Improvements included reduced length of stay
and proportion of patients leaving the EDs without being seen, fast tracking
of patients of low complexity, eliminating or combining steps in the process
and registration conducted using mobile workstations.
However, despite the benefits outlined, a survey carried out in 2009 by the
American Society for Quality (ASQ, 2009) highlighted that only 4% of U.S.
hospitals reported full deployment of Lean. However, 53% of the hospitals
did outline some level of Lean. Some challenges to the deployment of
process improvement will be outlined further in section 2.6.
A discussion of process improvement through the introduction of
information technology now follows in section 2.5. It is important at this
point to note that the application of a process improvement methodology
such as, Lean Thinking without introducing IT, as seen in some of the case
studies above, demonstrates the value that can be added by changes to
process alone.
2.7 Process Improvement based on the introduction of
Information Technology
As outlined in the introduction, the IOM (1999) suggests that IT must play a
central role in the redesign of healthcare to achieve substantial
improvements in quality. IT is an enabler and allows for the automation of
routine tasks which in turn, gives providers more time to spend with
37
patients. The connectivity provided by IT allows for better communication
among providers. Decision support assists providers with the analysis of
ever-growing amounts of information and ensures the right information is
delivered to the right people at the right time and in the right format which
aids decision making (IOM, 1999; NHS Institute for Innovation, 2007;
Victorian government report on streaming care, 2008). In this way, health
IT such as electronic records, digital technology for x-rays, mobile
technology, telecare, access to Map of Medicine can be extremely powerful
tools for improvement (NHS Institute for Innovation, 2007; Victorian
government report on streaming care, 2008). Bates (2002) states that IT
and high-quality healthcare are closely linked and that excellent clinical
outcomes at some healthcare organisations have been achieved in part due
to their information systems.
As outlined previously (section 2.4) measurement is a key component of
improvement. Data for improvement, generated from information systems
is often more accessible, timely, accurate and reliable than that created
manually. Finally, data mining allows providers to carry out statistical
analysis to determine outcomes of care, if processes need to be improved
and to carry out more extensive research (Hynes, et al., 2004).
In the context of process improvement Hughes (2008) advises that IT
should be used cautiously. IT exists to add value to a business, so that a
business in turn can add value to the customer. Bell (2006) outlines that IT
can be used effectively to simplify processes and add value, but if it is used
badly it can ingrain the very waste that should be eliminated. Automation
for automation sake is poor practice. Computers are amplifiers and if
inefficiencies are not first removed, the addition of IT will just lead to the
system becoming more inefficient faster (Diamond and Shirky, 2008).
Trinity Health and others outlined in the case studies above (2.6) have
demonstrated that process improvement prior to implementation of IT can
provide a solid foundation for IT implementation rather than simply
38
modelling existing, possibly problematic processes (Brokel and Harrison,
2009).
Bell and Orzen (2011) recommend that IT staff are active participants in
process improvement activities. Business and IT sections must integrate
and keep focused on delivering value to the customer. The authors
acknowledge that there can be misalignment between the business
processes and IT; IT can be seen as inflexible and resistant to change and
continuous improvement by the business side. Bell (2012) highlights the
need for guidance on how business and IT can integrate and suggests this
guidance may be found in the principles of Lean Thinking.
Bell (2013) tells us that the key to creating effective IT systems is engaging
employees in the simplification and standardisation of business processes
before investing in information systems. Bell (2006) indicates that
previously IT was often seen as waste to be removed rather than a tool to
help achieve improvement. Now IT is seen as a requirement for sustainable
improvement and he outlines that it is no longer possible to exclude IT from
the Lean Thinking approach. IT can make it difficult to revert to old ways of
working so can assist with sustainability of improvements (NHS, 2007).
Some examples of process improvements through the introduction of IT
were highlighted in section 2.6. There follows an outline of process
improvements based on the introduction of IT in physiotherapy.
2.8 Process Improvement and the introduction of Information
Technology for Physiotherapists
Physiotherapy specific literature makes up a very small percentage of the
growing body of literature on process improvement and health information
technology.
In Lean terminology physiotherapy can be seen as a functional bottleneck
as often physiotherapy is the last point in the patient journey and due to
waiting lists the flow stops and the patient waits. In a lean process the
patient would not have to wait but instead would be “pulled” from the
39
referring service to see a physiotherapist directly (NHS Institute for
Innovation, 2005; NHS Scottish Quality Improvement Hub, 2008).
In the UK the Department of Health commissioned service improvement in
Allied Health Professional (AHP) services in 2011, the aim of which was to
enhance quality and productivity through better outcomes and experience
for patients and carers. One of the main learning points from this initiative
was the importance of AHPs (Allied Health Professional) taking sufficient
time to first understand clearly the processes of the business they work in
and the importance of using data. In Barnet physiotherapy community
services wait times and Did Not Attends (DNAs) were reduced and a new
referral process was implemented. This was achieved through a demand
and capacity analysis, development of clear protocols and the use of
evidence based clinical outcome measures (Department of Health, 2011).
In Flinders Medical Centre in Australia, a similar initiative based on Lean
Thinking principles resulted in a reduction in waiting times and DNA rates in
two AHP services, physiotherapy and podiatry (Kitch, Crane, Ben-Tovim and
Daebeler, 2007).
The literature outlines how quality improvements can be achieved by
reviewing processes and introducing information technology in
physiotherapy, for example, by use of structured forms to improve data
accuracy and allow for the right information to be in the right place at the
right time, screening for contra-indications to treatments, improved
communication with the multidisciplinary team and improved research
capabilities (Barry, Jones and Grimmer, 2006; Vreeman, Taggard, Rhine
and Worrell, 2006; Buyl and Nyssen 2009). Shields, et al. (1994) found that
electronic documentation took 30% less time than paper documentation.
However, Vreeman, Taggard, Rhine and Worrell (2006) point out that apart
from the analysis by Shields, et al. (1994) few studies provide any
quantitative assessment of the impact of electronic recording in
physiotherapy.
40
Despite the benefits there have been limited examples of process
improvement through the introduction of IT in physiotherapy. In fact,
Vreeman, Taggard, Rhine and Worrell (2006) state that a 2004 review in
the USA showed only 26.4% of healthcare providers with EHR functionality
had implemented any components for AHPs and there were no plans to do
so in the future.
Through informal correspondence with physiotherapy managers the
researcher determined that there has been limited progress in the area of
process improvement based on the introduction of IT for physiotherapy in
acute hospitals in Ireland. Private hospitals in Ireland have made some
progress but there are still some outstanding issues such as duplication of
data entry into paper charts. Private practice physiotherapy services have
made most progress in this area but they are single service, stand-alone
systems with no necessity for the integration that would be required in an
acute hospital. These practices are at somewhat of a disadvantage in not
having access to on-line scan or x-ray results. However, some have
managed to achieve an integrated body chart, incorporated VAS (Visual
Analogue Scales) and % improvement scales into their electronic notes.
Physiotherapists can enter physiotherapy discharge status and are using
PCs and tablets.
Some physiotherapists overseas have made significant progress. Nitin
Chhoda is a physiotherapist in the USA and an early adopter of EMRs.
Chhoda (2012) outlines the benefits of EMRs which he believes should allow
clinicians to spend much less time on paper work and much more time with
patients. Chhoda (2012) also outlines a new innovation in physiotherapy
management that he calls self-intake technology. This is similar to the
initiative outlined previously in Vanguard urologic institute and allows
41
patients to carry out pre-visit registration saving time at a first
attendance12.
Choose and Book is in use by some physiotherapy services in the UK since
2008. The GP and patient can review waiting lists in their local area on line
and choose which location to refer to. Patients can leave their GP or
consultant knowing their referral has gone directly to their location of choice
which increases patient satisfaction. Physiotherapists can then triage
referrals on line and contact the patient with an appointment. The benefits
in terms of referral response times, improved communication, improved
access and reduction in time spent storing and retrieving referrals is well
established (Choose and Book, 2013).
Richardson (2011) outlines in his book how computerised clinical decision
support can be leveraged within physiotherapy electronic records to set up
computerised alerts and reminders to physiotherapists and their patients,
integrate clinical practice guidelines, condition-specific order sets, and
documentation templates and can give context and person specific
diagnostic support to the physiotherapist. The author suggests benefits in
terms of improved quality and productivity and patient outcomes, and
highlights that there is clear evidence that the use of evidence based clinical
decision rules allow physiotherapists to make decisions that are safer and
more efficient. One example outlined is the Virginia Mason low back
screening process which originated in the VMMC spinal clinic (Bisognano and
Kenney, 2012).
Work by Swinkels, et al. (2007) outlines that electronic clinical databases
for physiotherapy are in place in a few countries and are being used for
research, quality improvement and performance management. Clinical
outcome measures and numbers of patients was the main data collected.
12http://www.prweb.com/releases/PT-management/physical-therapy-
software/prweb10162237.htm
42
Many physiotherapy-specific challenges that have been cited include the
need for a body chart to allow for profession specific notations to be
documented (see figure 1.1) and access to laptop PCs or tablets to allow for
documentation at the point of care, both of which would match the current
workflow of physiotherapists in the out-patient setting (Buyl and Nyssen,
2009; Unertl, Weinger, Johnson and Lorenzi, 2009).
Chapman (2010) demonstrated how the challenge of the body chart could
be resolved through his work with SystmOne UK and a digital pen. The
initial implementation of SystmOne added 40 minutes to the time taken for
the physiotherapist to complete one patient’s notes. Using the digital pen
reduced this time dramatically and increased consultation time with patients
by 15 per cent. More time spent with patients meant a reduction in the
number of attendances for each patient as more could be achieved in a
single appointment. Chapman’s (2010) work demonstrated overall
productivity gains of 35 per cent as a direct result of using the digital pen13.
Further challenges are explored in the next section.
2.9 Challenges to Process Improvement
The characteristics of healthcare have been extensively outlined in the
literature as a challenge to any change initiative. These characteristics
include complexity, multiple standards of care, multiple stakeholders, intra-
professional boundaries, reluctance to engage and varying standards of
infrastructure.
With specific reference to process improvement, some authors outlined
further challenges: (Fine, Golden, Hannam and Morra, 2009; Powell,
Rushmer and Davies, 2009; Dixon-Woods, McNicol and Martin, 2012)
(1) staff concerns about jobs
(2) staff believing that the initiative is the current flavour of the month
13http://www.ubisys.co.uk/news/detail/digital-pen-and-paper-increases-
productivity-of-physiotherapists-by-35
43
(3) the difficulty with sustainability of some initiatives
(4) convincing staff of the need for change
(5) convincing staff that the solution is viable
(6) ability to access and continuously collect and monitor data preferably
through easily usable IT systems
(7) preventing unintended consequences at another point in the care
system
Fillingham (2008) highlights the difficulties with overcoming cultural barriers
and John Toussaint of Thedacare suggests the importance of being open
and honest about such cultural problems in any organisation14.
The importance of leadership as a success factor, and also as a challenge if
not clearly present and visible, is highlighted extensively in the literature
(Chyna, 2002; Fillingham, 2008; O’Connell, et al., 2008; ASQ, 2009;
Bowens, Frye and Jones, 2010).
Similar challenges to the introduction of health information technology have
been identified by some authors; lack of leadership, funding, buy-in from
staff, training or loss of expert personnel have also been cited in the
literature (Lapointe and Rivard, 2006; Vreeman, Taggard, Rhine and
Worrell, 2006; Buyl and Nyssen, 2009; Lluch, 2011; Rozenblum, et al.,
2011).
Fillingham (2008) suggests it is important to recognise the existence of
challenges and develop strategies to overcome them. With regard to staff
engagement Fine, Golden, Hannam and Morra (2009) put emphasis on
addressing “what’s in it for me?” for all staff involved. Staff involvement can
shift employees from merely carrying out the steps in a process to looking
14 http://www.lean.org/common/display/?o=1578
44
for ways to improve and feel empowered to suggest and implement change
(Scott, et al., 2011; Spear, 2005). `
When we acknowledge the link between structure (including staff roles and
responsibilities), process and outcomes the critical importance of engaging
with staff; those who are at the frontlines and will be impacted by any
change initiative cannot be overlooked (Berwick, 1992). Batalden (2006)
outlines how the greatest power for change lies at the front lines.
Virginia Mason Medical Centre (VMMC) believes that the key to
accomplishing the perfect patient journey is understanding that the staff
who do the work know what the problems are and have the best awareness
of process improvement opportunities (Kenney, 2011). Other authors
concur with the idea of learning about possibilities for improvement through
problem solving with staff rather than telling staff what to do (Berwick,
2002; Ben-Tovim, Dougherty, O’Connell and McGrath, 2008; Brokel and
Harrison, 2009; Mazzocato, et al., 2010; Holden, 2011).
However, while some studies in his review outline the positive effects of
involving staff Holden (2011) suggests that this positive effect may be due
to the Hawthorne effect, the phenomenon that change efforts bring about
positive effects in staff merely because more interest is paid to staff. Brokel
and Harrison (2009) also suggest that the release of clinical staff to
participate in process improvement can be a challenge and therefore,
involvement of clinicians should be done in a manner that meets their needs
(McGrath, et al., 2008).
The use of data to convince staff of the need for change and to demonstrate
that a change is indeed an improvement is reiterated at this point (see
section 2.2.1.4).
In summary the critical importance of frontline staff involvement, data
collection and easily usable IT systems and leadership is emphasised
(Batalden, 2006; Ben-Tovim, Dougherty, O’Connell and McGrath, 2008;
O’Connell, et al., 2008; Dickson, et al., 2009; Holden, 2011).
45
The importance of referring to the organisational change literature in more
depth prior to implementation of any process improvement is highlighted. A
brief overview of change management for process improvement is outlined
in the next section.
2.10 Change Management
“All improvement requires change but not all change is an improvement”
Don Berwick, IHI; 1996, p. 619
The link between improvement and change is indisputable as outlined by
Berwick (1996). Fillingham (2008) in the NHS outlines how process
improvement is as much about an understanding of culture and beliefs as it
is about techniques and tools. Crandall, et al. (2007) suggests change
management for implementation of IT in healthcare is one part technology
and two parts work processes and culture. Lorenzi (2000) takes this further
suggesting an 80/20 split between culture and IT implementation. Kaplan of
the VMMC recommends a clear commitment to change and very open
communication about expectations of any process improvement (Kenney,
2011). However, even with strong and committed leadership, some people
within the organization may be hesitant to participate in quality
improvement efforts because previous attempts to create change were
hindered by system factors; a lack of organization-wide commitment, poor
relationships, and/or ineffective communication (Eitel, et al., 2010). The
impact of these challenges was found to reduce if the organization
embraced the need for change.
The importance of identifying potential benefits and perceived challenges
cannot be overemphasised. These are important aspects of the change
management process as is the involvement of key stakeholders at each step
as outlined in the previous section. As emphasised by the Change
Management Framework of the Canada Infoway (2011), if stakeholders are
not engaged and cannot see potential benefits, change is less likely to be
successful. Therefore, any process improvement technique should have an
46
associated benefit for the key stakeholders; the patients and staff (Buyl and
Nyssen, 2009). However, it is acknowledged that sustaining change is a
continuous challenge but once processes are simplified and standardised IT
can assist hugely in the quest for sustainability (Bell, 2006; Brokel and
Harrison, 2009). IT systems, if designed and implemented appropriately can
make it difficult if not impossible to revert to old ways of working (NHS,
2007).
The Australian literature on Lean Thinking suggests the 8 steps for change
devised by Kotter in the 1990s offers a framework for the change
management process (Philips and Hughes, 2008).
2.11 Conclusion
Healthcare is embracing methodologies from manufacturing to improve
processes. Key areas of focus to date have been emergency departments,
laboratories, the admission and discharge processes through hospitals and
waiting times and numbers waiting for outpatient clinics. Some suggestions
for improvement are highlighted in the literature which are very relevant to
physiotherapy and include reduction in duplication of processes, elimination
of redundant processes, avoiding unnecessary follow-ups to improve
throughput, improving flow of patients and reducing unnecessary staff
motion. Once processes are simplified and as near to perfection as they can
be these processes should become standard work. There are some
examples of process improvement based on the introduction of IT while the
emphasis is on improving the processes and flow in the first instance.
Information Technology has a huge role to play in standardisation and
sustainability of any process improvement.
Improvement requires some essential elements for success: fostering a
culture of change, involving key stakeholders, leadership commitment,
standardising care processes, appropriate use of information technology and
allocating sufficient resources.
47
Physiotherapists have not been extensively involved in process
improvement and/or the introduction of IT to date so an awareness of the
various approaches and an acknowledgement of the key challenges and
success factors is very much a first step.
Through this literature review and the case studies outlined therein, the
researcher identified process improvement methodology and tools based on
the principles of Lean Thinking are appropriate for use in the physiotherapy
outpatient setting. Lean Thinking principles are simple, yet powerful. The
focus is on the process rather than specific problems and the customer is
always at the centre. Staff engagement is crucial. Data to highlight where
processes could be improved and if a change is indeed an improvement is a
key factor. This data needs to be meaningful to all and not involve complex
statistical analysis. The next chapter outlines the methodology used in this
research in further detail.
48
CHAPTER 3
RESEARCH METHODOLOGY
3.1 Introduction
This chapter outlines the methodology used to assist in answering the
research questions.
Main Question (MQ):
How can processes be improved in a physiotherapy outpatients
setting?
Sub questions:
What process improvement methodology is appropriate to apply in
the physiotherapy outpatient setting? (SQ1)
Which processes should be improved? (SQ2)
How should processes be improved? (SQ3)
What are the potential benefits of any suggested improvements?
(SQ4)
What are the perceived challenges of any suggested improvements?
(SQ5)
A mixed methods exploratory case study design was employed. Baseline
quantitative data was collected and a literature review carried out. Through
the literature review the researcher identified a process improvement
methodology and tools based on the principles of Lean Thinking as an
appropriate methodology for use in the physiotherapy outpatient setting.
Following baseline data collection and the literature review, the three stages
of applying the process improvement methodology took place: process
mapping, semi-structured interviews and a focus group. Further
quantitative data was collected at the process mapping stage. This process
improvement methodology and the tools chosen closely resemble those
49
used by the redesigning care programme in Australia (Ben-Tovim, et al.,
2008; Victorian Government Department on streaming care, 2008).
As outlined previously (section 2.5.6) the first step is to map the process.
Next the map should be analysed and improvement ideas prioritised. Before
starting and during the observation stage data is collected to assist
prioritisation and to determine after implementation if a change is indeed an
improvement. Keeping the patient at the centre and the engagement of
staff is crucial. Armed with this knowledge the first stage of applying the
process improvement methodology was to map the process of the patient
journey while involving staff in the clarification and validation of the process
maps. Following this mapping, potential process improvements and
associated benefits and challenges were garnered from the literature,
interviews and the focus group. While the scope of this research did not
involve the implementation all improvements some initial changes have
been made and the impact on the baseline data and other measures will be
closely monitored going forward.
3.2 Background
The location of this research study was the physiotherapy outpatient
department of a large acute teaching hospital. The department is not
located in the main hospital outpatients department and is at the very edge
of the campus.
The focus for this study was the orthopaedic and rheumatology patients
referred to the service as they make up the highest percentage (71%) of
referrals that go through the complete range of processes and so they were
a useful sample (see further explanation of local context in section 1.1).
3.3 Study design
The approach to this research was that of a case study concentrating on the
specific case of the physiotherapy outpatients department of a large acute
teaching hospital but it is hoped that the process improvement methodology
identified and results of applying this methodology can be leveraged for use
50
by other departments, physiotherapy and other allied health professional
settings.
3.4 Methodology
A literature review was completed to identify (1) an appropriate process
improvement methodology for the study setting (SQ1) (2) process
improvements carried out elsewhere (SQ3) (3) potential benefits (SQ4) and
(4) perceived challenges (SQ5). Referring back to the research questions,
the literature review assisted with answering the questions on the most
appropriate process improvement methodology, how processes were
improved elsewhere and the resulting benefits and challenges. It also gave
the researcher some improvement ideas that could be applied in the
setting.
As outlined in section 2.3.1 Lean Thinking as a methodology is often
selected where an organisation values a visual improvement along with
positive changes in efficiency. Referring back to the issues identified by the
researcher (section 1.1) before commencing this research, the principles of
Lean Thinking were deemed the best fit for the department under study.
Section 1.1 identified waste from use of paper and disparate IT systems,
lack of standardisation for some processes and the need for improved
efficiency due to reduced clerical capacity.
Baseline data was collected. This data was used to assist in determining
which processes should be improved (SQ2) and will be used to determine if
any future change is an improvement. The baseline data gives an indication
of the department throughput; number of notes filed and retrieved, phone
usage and costs and is outlined in section 4.2.
As outlined in section 1.1.1 the waiting times and throughout data is
requested by the HSE each month. Waiting does not add value to the
patient experience and can lead to conditions moving from an acute to a
chronic phase and inability to work. Patients want to have access to a
service without a delay, not when the system determines this for them
51
(Campbell, 2009; Murray, 2009). Patients also want to have access to any
appliances they require; this is not always possible due to non-pay budget
constraints, a budget which is also used for the purchase of paper and
printing components. Unanswered phone calls from patients are not
providing a patient-centred service.
Application of the process improvement methodology addressed sub-
questions SQ2, SQ3, SQ4 and SQ5 (to a lesser extent) and was made up of
three distinct stages:
3.4.1 Stage 1: Process mapping
As outlined in section 2.5.6 the first step towards improvement should
always be to map the process. Referring to figure 2.2, this stage is in line
with the Lean Thinking principles of all steps adding value for the customer
(patients and staff), mapping, creating flow and establishing pull.
Mapping allows all staff involved in the patient journey to visualise the
complete journey and can clearly highlight which processes need to be
improved (SQ2). Steps may not add value and timing of steps can assist
staff to realise the time taken to complete steps some of which may not add
value. Therefore, the processes were documented at a high level and in
detail through observation of all processes. The scope of the process
mapping and observation was the complete patient journey through the
physiotherapy outpatients department from the patient’s referral to the
service to discharge and/or onward referral. Many studies focus on the
patient journey from the point of arrival for a service (Dickson, et al.,
2009). However, the researcher was also interested in a more detailed
review of the processes involved in the period from referral to actual
appointment to determine what if any value was added. The observation
was carried out by the researcher and included measuring the time taken to
carry out some key steps in the process, for example; to retrieve and file
physiotherapy paper notes and to access relevant patient information. Time
was measured with a stopwatch mobile phone app. In parallel to the
52
process mapping, information flow in terms of documents and data
generated and information accessed was also documented.
Ten participants made up of 8 physiotherapy and 2 clerical staff were
recruited for observation. Participants were drawn from the staff of the
physiotherapy department and were a convenience sample dependent on
which staff members were available and willing to volunteer at the time the
study was taking place. Consent was received from all participants. There
are three grades of physiotherapy staff working in the outpatients
department and one clinical specialist, two seniors and five staff grade
physiotherapists were recruited. The staff grade physiotherapists rotate
through the hospital to a different area every four months and this
happened midway through the observation stage. Therefore, staff at each
grade and staff grades with different levels of experience in the area were
observed.
An initial pilot of data collection took place in early January 2013 to finalise
the data collection sheet and determine the best way to randomise the
observations. Following this it was decided that observing the complete
patient journey from referral to discharge in sequence was not realistic as
the process steps occur at different times and some processes were a bit
adhoc. Therefore, this approach would not be an efficient use of the
researcher’s time and would not yield sufficient data.
For patient interactions such as patient registration, booking of
appointments and the patient being alone in a cubicle while the
physiotherapist accesses relevant information the researcher decided to
observe a maximum of one patient every 15 minutes. Other steps that took
place during the observation were documented and timed as they occurred.
A total of 7.49 hours observation was carried out on various days (Monday
to Friday) and at various times. Various days and times ensured
documentation of a representative process map of both busy and quiet
periods and ensured an even distribution of staff were observed.
53
The researcher was positioned at a desk in the reception area to allow
visibility of the clerical staff while blending in in so far as possible. The
researcher would have a presence at the reception area in any case and did
not announce every time she was carrying out the observations. This was
an attempt to reduce performance bias.
Throughout the observation, the researcher recorded notes on observations
and anything that required clarification.
To acquire further detail on some of the process steps it was sometimes
necessary for the researcher to request clarification at the time from the
observed staff member.
The process map was documented in Microsoft Visio after each observation
session. Standard process map symbols were used as these are easily
understood and currently used at the site under study. Value stream maps
were not used as the researcher did not wish to make any assumptions at
the observation stage about which steps did or did not add value as
determined by the customer (patients and staff).
In between observations, a reflection session and iterative construction of
process maps was used to highlight gaps in knowledge about the processes
and guide subsequent observations. The level of detail outlined in the
process maps was determined by what was observed during the observation
sessions and what clarifications were gained within the timeframe of the
study. It is acknowledged that some gaps remain which were highlighted to
some extent through the interviews and focus group. Timings of steps and
reflections on the observations were recorded in Microsoft Excel after each
observation session. Descriptive statistical analysis was carried out on these
timings and mean times documented on the Visio process maps. Following
observation and documentation of the process maps in Visio the maps were
validated by those observed. This added credibility to this stage of the study
(Wallace and Savitz, 2008). The resultant process maps are presented in
section 4.3.
54
3.4.2 Stage 2: Semi-structured interviews
As outlined in section 2.5.2 interviews and focus groups are ways of
gathering qualitative data to aid process improvement initiatives.
Referring to figure 2.2, this stage is in line with the Lean Thinking principles
of all steps adding value for the customer (patients and staff), creating flow
and establishing pull.
Three semi-structured interviews with key physiotherapy informants who
have implemented process improvements and/or health information
technology were undertaken. The interviewees assisted with answering the
research questions as they reviewed the process maps in the study setting,
outlined where improvements could be made (SQ2), gave clear suggestions
as to what those improvements would look like (SQ3) and their potential
benefits (SQ4) and finally they gave some advice about challenges and how
to manage them (SQ5).
Five experts were originally identified through the literature and word of
mouth and were asked for their voluntary participation. Four agreed to
participate but one subsequently had to withdraw for personal reasons. All
three were physiotherapists, one has a diploma in Lean healthcare, and the
other two participants have implemented process improvements through
the introduction of IT; one in an Irish private practice and the other at a
UK-based acute /community trust.
Once consent had been received from participants they were e-mailed some
background information on the department under study, some of the
baseline data and the detailed process maps. This information was sent a
minimum of 3 weeks prior to interview to allow the participants sufficient
time to review the detailed maps. Interviews were by telephone and took
approximately one hour (total time spent interviewing was just over 3
hours) and written notes were taken by the researcher during the interview.
Interviews were conducted as per the protocol outlined in Appendix B.
55
The interviewee was encouraged to talk about the process maps and the
questions were not necessarily asked in sequence but before ending the
interview the researcher asked if the interviewee wished to add anything to
each of the questions as outlined in the protocol by going through each
question systematically. Each set of individual interview notes were sent to
the interviewees for validation. While the conversation of the interviews did
not flow from one question to the next the researcher’s notes were
organised according to the questions outlined in the protocol. Similar
comments and ideas emerged from these interviews and it was felt that
further interviews were unlikely to yield additional insights.
3.4.3 Stage 3: Focus group
A focus group with key stakeholders was carried out. Eight participants
were involved in the focus group which included physiotherapists (n=5),
clerical staff (n=1) and IT staff (n=2). Participants were a convenience
sample dependent on which staff members were available and willing to
volunteer at the time. Eleven people expressed an interest in participating
but due to work demands 2 IT staff and 1 clerical staff member had to
withdraw. The final group was made up of one clerical staff member, two IT
staff, three physiotherapists from the out-patient area and two
physiotherapists who previously worked in the area and have a keen
interest in IT and/or quality improvement.
The focus group assisted with answering the research questions as staff
reviewed some of the baseline data and the process maps with timings and
identified which processes could be improved (SQ2) and how (SQ3).
Following this they prioritised the improvements and outlined what they felt
the benefits of each improvement could be (SQ4).
The focus group took place from 11:30 a.m. as this time was most
convenient for participants and had the least impact on patient contact
time. The venue was on the site of study but in a location very much
56
separate from the physiotherapy outpatients department where staff would
have space to give their full participation with no interruptions.
At the focus group the process maps from stage 1 were displayed on A1
size posters at four stations. The documents, data and information accessed
tables and the outline of repositories were also displayed in a separate area
of the room on A1 size posters for participants to refer to.
The session began with a brief introduction to the purpose of the focus
group, an outline of findings from the literature and the goals of any
suggested improvements. Participants were encouraged to add to the goals
throughout the session or to remove any they did not agree with. The goals
were displayed throughout the focus group and reiterated again prior to the
regroup and discussion session. There was agreement to maintain them as
they were.
Goals:
Improve patient journey and the importance of keeping the patient at
the centre
Boost staff morale
Reduce non-value added activities, for example, waiting, duplication
and movement
Reduce non-clinical steps for the physiotherapists
Improve ease of access to information – both when the patient is
present (patients with multiple attendances) and to review service
outcomes and carry out research
Referring to figure 2.2, these goals are in line with the Lean Thinking
principles of adding value for the customer (patients and staff), creating
flow and establishing pull.
From the department’s “comment cards” process; of note, patients have
very few complaints but access to the service and waiting times are
commented on. Therefore value from the patient’s viewpoint is access to
57
the service when they need it and not when their problem is chronic, to
have their queries answered and to have the therapist spend time with
them and explain their condition.
Some of the baseline data was also presented (see section 4.2).
Following collection of consent forms from all participants they were divided
into groups of two and asked to review the process maps to identify where
improvements could be made. Each group of two had 12 minutes to review
each station. Each group of two had at least one member currently working
in the physiotherapy outpatients department. Each group had a flip chart
and a specific colour pen on which they documented their ideas for process
improvement. After 12 minutes the groups rotated clockwise to the next
station, reviewed what the previous group had documented, ticked the
ideas they agreed with and added to this list. This method of group work is
one of the suggested activities outlined in the NHS leaders’ guides (2005)
section “Working with groups”.
When each pair had visited each station the full group took a break for
lunch. Following lunch the full group came together to discuss the ideas
presented and to outline potential benefits and perceived challenges of any
suggestions. The focus group took 2.5 hours in total. In all 19 items were
listed as improvement opportunities. The number of ticks allowed clear
visibility of the opportunities highlighted most frequently.
Notes from the focus group were transcribed into a table by the researcher,
listing each item against any benefits and challenges outlined at the focus
group and were distributed to each participant by e-mail. Participants were
asked to state whether they agree/not agree that each item should be
explored and to prioritise the items for which they said “yes”, giving 1 to
their highest priority. All responses were amalgamated into a master
priority list and an average score was assigned to each item (total assigned
to item/number of responses to the item). If average scores were equal for
58
two items the item that received the higher number of “Yes” responses was
given the higher priority.
3.5 Participants and recruitment methods
All participants were asked to sign a consent form (Appendix C) before
participating. The same consent form was used for all three stages. For
semi-structured interviews (stage 2) consent forms were sent by e-mail and
confirmation of agreement to participate was received by e-mail.
Participants in each stage of this research study were given a [stage
specific] information sheet a minimum of two weeks in advance of the study
stage outlining the purpose of the study and requesting their voluntary
participation (Appendix D). Each information sheet includes a statement
“Your participation is voluntary and you are free to withdraw at any time
without providing a reason”. One participant who had agreed previously to
participate in a semi-structured interview had to withdraw for personal
reasons.
3.6 Ethics application
Ethics was sought from the ethics committee at the acute hospital site and
was deemed unnecessary. An application to the Trinity College Dublin
(TCD), School of Computer Science and Statistics Research Ethics
Committee was then submitted and approval received following one
requested change. This study conformed to the conditions of the ethical
approval obtained (Appendix E).
3.7 Conclusion
This chapter has detailed the design of the research study and its
implementation. The methodology outlined assisted in answering the
research questions as described in the text.
The Mixed Methods approach (Creswell, 2009) used, allowing for the
collection of both quantitative and qualitative data and also data from a
variety of sources increased the validity of the data and findings.
59
The results of all three stages are presented in the following chapter. While
the scope of this research did not involve the implementation of all
improvements some initial changes have been made and the impact on the
baseline data and other measures will be closely monitored going forward
(section 5.4).
60
CHAPTER 4
RESULTS
4.1 Introduction
This chapter presents the quantitative and qualitative data collected by the
researcher. Baseline data and the process maps including a brief narrative
of each map are presented initially. Thereafter, data from the semi-
structured interviews and focus group are presented.
As outlined in chapter 3 data from all three stages of applying the process
improvement methodology; process mapping, semi-structured interviews
and the focus group was reviewed and validated by participants which
added to its validity given that one researcher carried out each stage
independently.
Throughout this chapter numbers I1,2,3 etc. refer to the suggested
improvements and/or the point in the process map to which the suggested
improvement applies, as identified in this research. These numbered
suggested improvements are listed in table 5.1 in section 5.3.2. They are
ordered in the table starting with the suggestions whose implementation is
complete or further advanced. This is an attempt to add clarity for the
reader regarding which suggested improvement/point in the process the
researcher is referring to.
4.2 Baseline data
As outlined in Chapter 3, as part of this study baseline data was collected.
The baseline data gives an indication of department throughput, numbers
waiting and time to wait, unanswered calls and estimated paper and storage
costs and is outlined in the tables and text below. As outlined by Ben-
Tovim, et al. (2008) data is an important part of any process improvement
initiative and the measures used need to be important to patients, the
organisation and the health service in general. The data chosen impacts all
three aspects with the patient at the centre.
61
Table 4.1 illustrates the number of referrals, number of new and return
patients seen and the waiting time and number of patients waiting per
month for each of the two specialties under study. The DNA for both
specialties is also outlined.
4.2.1 Throughput
Table 4.1 Throughput (average per month in 2012)
Orthopaedic Rheumatology
Referrals 170 46
New patients seen 140 27
Return patients seen 422 104
New to Return ratio 1 : 3 1 : 4
Number of patients on
the waiting list
46 38
Waiting time for
patients
6 weeks 5 weeks
Did Not Attend (DNA)
rate
9% 7%
As illustrated in table 4.2 the clerical staff retrieve the physiotherapy notes
and make up and file away the notes of patients attending for the first time
(new patients) each day. The physiotherapists file away the notes of all
patients returning for a second or subsequent appointment (return
patients). See process map 4.11 in the next section for timings on this
section of the process.
62
4.2.2 Retrieval and filing of physiotherapy notes
Table 4.2 Physiotherapy notes retrieval and filing (average per month)
Number of physiotherapy notes
clerical staff retrieve monthly
526
Number of physiotherapy notes
physiotherapy staff file monthly
526
Number of physiotherapy notes
clerical staff file monthly
167
Number of new sets of
physiotherapy notes made up by
the clerical staff monthly
167
Table 4.3 illustrates the high volume of calls that the clerical staff have to
deal with and highlights that 20% of calls are unanswered (I3). Calls to the
department are mainly from patients to (1) cancel their appointment (2) to
book an appointment (3) to determine where they are on the waiting list
and (4) how long they will wait.
4.2.3 Phone calls
Table 4.3 Phone calls (average per month in 2012)
Number of calls in and out of the
physiotherapy outpatient’s main
reception
2760
Average time per call 63 seconds
% of calls that were unanswered 20.46%
63
4.2.4 Costs of paper and storage
Each set of physiotherapy notes has an average of 8 pages. This
includes the referral, a front sheet, a pre-printed assessment sheet, a
database and blank sheets for SOAP notes (see figure 4.3).
This paper along with printing components costs an average of
€2,220 per annum.
Appointment cards cost an average of €145 per annum.
Text messaging has no on-going cost (Ref. IT department)
Active physiotherapy notes are stored in a shelving unit with a
tambour door. Each set of physiotherapy notes has its own cardboard
file which is recycled so there is a negligible cost involved.
Physiotherapy notes that have been discharged are filed in the
current and then old archive. Notes are destroyed after 8 years and
the filing cabinets are recycled so there is a negligible cost involved.
Source of baseline data:
Phone usage data is automatically generated
Numbers of new and return patients is a monthly report generated by
the IT department based on data inputted to the PAS at the point of
patient registration
Paper costs; actual price comes from the SAP requisitioning system
and the overall cost was manually calculated
Number of referrals is counted manually
Waiting numbers and times are counted manually
4.3 Process Maps
The methodology used for the observation and process mapping stage is
outlined previously in section 3.4.1. The researcher believes that
documentation of the processes through observation by the researcher
rather than staff outlining the processes was an accurate representation. As
outlined by Unertl, Weinger and Johnson (2006), staff may have difficulty in
64
providing a complete description of their processes because they are
immersed in the work. Use of a single researcher also eliminated intra
observer bias. As outlined previously by Crandall, et al. (2007) attention to
detail in the lower level maps is important to determine how to improve
existing processes and how best to integrate healthcare IT into processes.
The outputs of the observation stage are depicted in the process maps on
the following pages. Overall the process maps clearly indicate that this is a
very busy department with very complex processes producing a high
volume of documents and data which are accessed from a variety of
repositories (see figure 4.3 and tables 4.4, 4.5 and 4.6). When the maps
were documented some opportunities for improvement were visible to the
researcher; the need to simplify, standardise and make better use of
existing IT systems.
The process maps presented are those based on the observations that the
researcher carried out. As outlined in sections 4.4 and 4.5 some
clarifications were sought on steps in the process maps, both during the
semi-structured interviews and at the focus group, but the researcher did
not adjust the maps accordingly but did take note of all clarifications
requested (see section 4.5).
During the observation and process mapping stage some opportunities for
improvement emerged and it was agreed that these changes should be
carried out (Just do it! in Lean Thinking which might be more akin to action
learning than a case study). These opportunities included the need to clarify
the policy of booking new patients into return patient slots for all staff (I1)
and standardisation of the notations for the body chart diagram (I2). These
changes are not reflected in the initial background information or the
process maps as the researcher thought it best to clearly demonstrate the
starting point of the study.
The process maps are now outlined. Figure 4.1 outlines the high level
process map broken down into the key blocks that make up the patient
65
journey from referral to discharge. The separation into blocks emerged
naturally with the iterative construction of the process maps between each
observation session. Blocks A-D are detailed in figures 4.4 through 4.10.
Figure 4.2 is an overview of key repositories of patient information. Figures
4.4 to 4.10 are lower level process maps of the blocks outlined in the high
level map (4.1). Figure 4.11 outlines the process for filing and retrieval of
physiotherapy notes and figure 4.12 clinical documentation and information
access during the patient attendance. Tables 4.4, 4.5 and 4.6 outline
documents and data created and information accessed. Each is described in
the following sections. More detail on each of the notations outlined on the
process maps is available in Appendix F.
66
A Referral Triage and
Management
Internal Referrals from Hospital Consultants
External Referrals from Other
Hospitals and GPs
BWaiting List
Management and Appointment
Booking
CPatient Attendance
DPatient Discharge &
Referral Onwards
Internal Referrals from Hospital
physiotherapists attending
consultant clinics
1 Documents
3 Information
Accessed
2 Data
Documents, Data and Information Flow
Patient Non-Attendance
Community or Local Hospital
RescheduleAppointment
DNA first appointment or appointment not rescheduled within 2 weeks
Follow-up appointmentneeded
Figure 4.1 High level process map
67
As illustrated in Figures 4.2 and 4.3 information is stored in a number of
locations many of which do not join up together leading to multiple points of
data entry (some of which are paper-based and some electronic) and
storage and much duplication. Access to the IT systems is limited by the
number of computers available and accessing any information involves
movement of staff and/or paper.
68
PAS
PhysiotherapyNotes
EPR
Monday
New Referrals Box
PhysiotherapyReferral
PhysiotherapyReferral
PT REF
Referrals database
Old Archive
Waiting List folders
Lists for each clinic
Active Notes
Clinic Name Alphabetically
Current Year Archive
DNAs Box
YellowAppointment
card
ConsultantCorrespondence to GP
PT NOTES
APPTCARD
WLFOLDER
Community database
COMM DB
REFSDB
NEW REF BOX
ACTIVE
DNA
CORR
CLIN LIST
OLD
CURRENT
KEY REPOSITORIES
Waiting ListNumbers
WL NUMBERS
DB
Figure 4.2 Key Data Repositories
69
PAS
EPR
Monday
New Referrals Box
EPRPhysio
Referral
Referrals database
Old Archive
INTERNALEXTERNAL
PaperPhysio
Referral
PaperPhysio
Referral
Physio Notes
Physio triage trayTransport
Transport
Clerical tray
Triage &Transport
Data entry
Waiting List folders
Referrals in
Appointmentbooking
ReferralsPut in Patient
Paper AssessSheet
PaperDatabase& blank sheets
Print off PAS
FrontSheet
Physio Referral
Physio Referral
Remove
Clinic Lists
New file made up and file
Active Notes
Clinic Name
Alphabetically
Notes of patients per clinic
Current Year Archive
DNAs Box
Retrieve
Retrieve
After 8 years Destroy
Research or audit
Retrieve
Cancelled andNo contact in 2 weeks
discharge
Transported toPhysiotherapist’s desk
File
PatientDNA
No contact in 2 weeks
discharge
No further treatment required discharge
For community
Into Area Envelope
AccessedFor scans and blood results
Register
Handed
Appointment card
File
PlaceReferral
Complete
Discharge or update
letter
Entry
Printed
Retrieve
Outcome Measures
PhysioTools package for HEPs
ConsultantCorrespondence to GP
Accessed for more detail Accessed, completed
And put into notes
Accessed, printed And handed
to patient
Physio Notes
Figure 4.3 Data storage and access
70
A6
Referral reviewed for triage
A5
Referral transported to main out-patient department
A9
Referral transported to main out-patient reception
Resource: Clerical staff
Av Task Time to complete steps A3, A4 and A5 for each referral = 10.5 seconds
Done in batches
Resource: Physiotherapist
Av Task Time to complete steps A6, A7, A8 and A9 for each referral = 39.38 seconds
Done in batches
A3
Referral lifted from printer
A4
Referral completed on EPR
A10
Referral data entered into Excel spread sheet
A11
Referrals separated
Resource: Clerical staff
Av Task Time to complete steps A10 and A11 for each referral =38.7seconds
Done in batches
AREFERRAL MANAGEMENT
AND TRIAGE
A2
Paper referral from external source
arrives
A1
Referral placed on EPR
A7
Triage category written on referral
A8
Code written on referral
A12
Community or local hospital referral?
YES
NO
To D Discharge
To B Booking
PhysiotherapyReferral
PhysiotherapyReferral
PT REF
Referrals database
Referrals database
REFSDB
Community database
Community database
COMM DB
Figure 4.4 Referral Management and Triage
71
The process for referral management and triage (I4) was mapped in detail.
As outlined in section 2.5 it is important to map in detail at any bottlenecks.
This stage is an obvious bottleneck in the patient journey as referrals arrive
and patients wait for an appointment. As illustrated in Figure 4.4 referral
management and triage involves 9 steps, takes a mean of 88.6 seconds per
referral (n=35) and entails a lot of walking about for staff and movement of
paper from one place to another. The 9 steps in the process are purely to
determine the patient’s priority and to decide a physiotherapy diagnostic
code. This process takes up to 16 minutes (for orthopaedic and rheumatology
referrals only) of staff time each day and adds little value to the patient
journey apart from ensuring that those patients who are in urgent need of
physiotherapy are seen first. Referrals are triaged daily in batches which
causes a delay between receipt of each individual referral and the referral
going on to the waiting list and the patient actually receiving an appointment.
However, the researcher acknowledges that due to the significant amount of
movement, carrying out this process on each individual referral would
actually add to the time taken to complete the steps. An example illustrates
this clearly and highlights the amount of time wasted on movement of staff
and referrals. The mean time it took one of the clerical staff to complete
steps A2, A3 and A4 for 5 referrals was 20.71 seconds per referral whereas
this mean time reduced to 8.3 seconds per referral for a batch of 30 referrals.
72
B (a) 5Ring the next patient
B (a) 2PAS reviewed to determine what free new slots are
available
B (a) 3Free new slots written on paper
B (a) 8Clinic lists reviewed to determine what
return slots are not filled
NEW APPOINTMENT BOOKING
B (a) 10Return appointment
booked
Resource: Clerical staffAv Task Time per appointment = 60.64 seconds
FOLLOW UP APPOINTMENT
BOOKING
B (a) – WAITING LIST MANAGEMENT AND APPOINTMENT BOOKING
B (a) 1 Manual waiting list folders reviewed
simultaneously with PAS
OR
From A
B (a) 9Follow-up
Appointment Required?
To D Discharge
B (a) 4Manual waiting list folders reviewed
B (a) 7Patients booked in to
all of the available clinic slots on the PAS
To C (a) Patient
Attendance
YES
NO
PAS
Waiting List folders
WLFOLDER
To C (a) Patient
Attendance
B (a) 6Patient self-
dischargeNO
YES
From C (a) Patient
Attendance
Figure 4.5 Waiting list Management and Appointment Booking
73
The process map for waiting list management and appointment booking
(figure 4.5) shows a waiting list folder (WL folder). This is where all paper
referrals are stored. This manual folder exists despite most referrals
(internal consultant referrals make up 95%) already being on the EPR
system. This process follows on from figure 4.4 triage. As outlined
previously in table 4.1 (section 4.2) the timeframe from referral received to
appointment booking can be up to 6 weeks.
With regard to taking patients off this manual waiting list and ringing them
to book an appointment it is not clear who is responsible for this; all clerical
staff or one or if done on all or specific days? During the observation the
researcher noted that both clerical staff took on this duty while carrying out
multiple other tasks with multiple interruptions. As seen in the process map
there were two ways that the two clerical staff carried out this process one
of which appears more efficient than the other (B (a) 1 directly to B (a) 5)
(I12).
Staff did not seem to be clear on the expectation that all new slots were to
be filled 3 weeks in advance or what the guidelines are for booking new
patients into return slots (if they are vacant). The booking policy states all
new slots in the clinic templates should be filled 3 weeks in advance. It is
not in the booking policy but clerical staff understand that return slots can
only be filled with new patients 1 day in advance so they do this following
printing of clinic lists which leads to the patients getting an appointment at
very short notice. On the other hand, the physiotherapists said they are
happy for new patients to be booked into return slots 3 days in advance. As
the understanding of expectations and clarification on the policy was
required a decision was made to meet with staff and seek agreement on the
policy (Just do it!) (I1).
Clerical staff also said they could ring 20 patients and manage to make only
4 appointments and the question must be asked if this is an efficient use of
their time or if an alternative time or method for making appointments
needs to be considered. The time taken to book new appointments was not
74
recorded as there were so many variations in understanding of the booking
policy and the process for booking that time did not allow for this to be fully
assessed and timed.
There was significant variation in the time taken to book a return
appointment; ranging from 28.7 to 124.9 seconds (mean 60.64 seconds
SD+/- 35.38 seconds) per patient (n=15). There were some reasons noted
for this variation including interruptions from other staff and interruptions
from phone calls. While the stopwatch was stopped while interruptions were
dealt with the staff member was obviously distracted on returning to finish
the booking.
75
B (b) 13PAS checked to see
when patient was with consultant?
B (b) - WAITING LIST REPORTING AND QUERIES B (b) 6
Patient phones re referral status
B (b) 7Patient queried when
with consultant?
B (b) 8EPR reviewed
Referral placed?B (b) 11
Patient advised referral received
NO
B (b) 12Patient advised
no referral received and
patient referred back to
consultant
B (b) 8EPR reviewed
Referral placed?
YES
YES
B (b) 9Waiting list folders
reviewedReferral in there?YES
NO
B (b) 10Spread sheet checked
Referral entered?
NO
OR
B (b) 10Spread sheet checked
Referral entered?
NO
NO
YES
YES
To B (a) Booking
B (b) 3Numbers waiting manually counted
B (b) 1Management request
report of numbers waiting and waiting
time
B (b) 2Manual waiting list folders reviewed
B (b) 4Waiting time calculated for urgent and routine
referrals
B (b) 5Data entered on Excel
waiting list spread sheet
Waiting List folders
Waiting List folders
WLFOLDER
Waiting ListNumbers
Waiting ListNumbers
WL NUMBERS
PAS
EPR
Referrals database
Referrals database
Waiting List folders
Waiting List folders
WLFOLDER
REFSDB
Figure 4.6 Waiting List Reporting and Queries
76
Figure 4.6 illustrates the process followed for calculation of numbers waiting
and waiting time. This process is completely manual.
An observation from this process map is to query why the manual process
of data collection occurs given that all of the data is inputted in to the PAS?
As explained in section 1.1 the referral is date stamped on the EPR system
and the appointment then booked on the PAS and these two systems do not
link up. As will be seen in the next sections (4.4 and 4.5) the question as to
why waiting list data cannot be calculated automatically was asked by some
participants at the focus group and by two of the interviewees (I5).
Figure 4.6 also illustrates that the process for answering a patient query is
not standardised and involves the checking of multiple systems storing
similar information (I13).
77
C (a) 2
Patient arrives
C (a)PATIENT
ATTENDANCE
C (a) 4
Patient is registered as
a NEW attendance
C (a) 6
A front sheet is printed out
C (a) 8
Physiotherapy notes are made up
C (a) 3First
attendance?
YES
NO
C (a) 9Patient is
registered as a RETURN
attendance
C (a) 10Patient is
treated by the physiotherapist
C (a) 11Further treatment required
[based on clinical need]?
C (a) 1
Patient receives appointment
reminder
To C (c) Registration
YES
To B (a) Booking
To D Discharge
NO
From B (a) Booking
C (a) 7Department policies and
appointment card issued
PAS
PhysiotherapyNotes
PT NOTES
APPTCARD
From B (a) Booking
Monday
NEW REF BOX
C (a) 5
Referral is retrieved from
the new referrals box
Figure 4.7 Patient Attendance
78
The process that occurs when the patient attends the department for a new
or return appointment is outlined in figure 4.7. Information gathered and
accessed by the physiotherapist at step C (a) 10 is illustrated further in
figure 4.12. Similar to the triage process outlined in figure 4.4 there is
much movement and gathering of pieces of paper for a new patient
attendance (I11). The physiotherapy notes are not made up in advance of a
new patient attendance to avoid time wasting in the case of non-
attendance. However, as can be seen some of the steps, for example,
registration at C (a) 4 (new) and C (a) 9 (return) do not add value to the
patient’s journey while this step does allow for automatic calculation of
numbers attending. Step C (a) 6, leads to the printing of a front sheet and
it is unclear what this is actually used for (Table 4.4) (I6).
Registration is mapped in more detail in figure 4.8. The researcher
acknowledges that there is more than one step in each box and would like
to state that this section of the process map was represented
diagrammatically purely to demonstrate the time taken to complete patient
registration of a new and return patient. The mean time taken to register a
new patient was 62.36 seconds (SD +/- 23.23 seconds) with an extra 41.52
seconds (SD +/- 12.32 seconds) on average to gather up the pieces of
paper needed to make up the physiotherapy notes (n=7).
The mean time taken to register a return patient (I10) was 12.6 seconds
(SD +/- 16.47 seconds) (n=13). Therefore, a significant amount of time is
taken to register patients and as stated above this adds no value to the
patient as it purely acknowledges their arrival but it does allow for
automatic calculation of the number of attendances. Of note, if a patient
arrived without their yellow appointment card for a return appointment this
caused delays in the registration process as there are important details such
as the clinic code, consultant’s name and physiotherapist’s name written on
the yellow card and these details are required by the clerical staff to register
the patient (I7). One example clearly illustrates this where the patient had
no yellow card, was unclear who their consultant or physiotherapist were
79
leading to the registration taking 56.4 seconds to complete. The
physiotherapist/consultant details are currently not in the text message
reminder sent to patients (step C (a) 1).
During patient attendance clerical staff are engaged in multiple
simultaneous tasks which can lead to many interruptions. As seen in the
study by Chand, et al. (2009), any external disruption while registering a
patient lengthened the registration time. A consistent example of this was
interruption by phone calls, whereby the registration process was
interrupted and the phone call answered and then put on hold while the
registration process was completed.
80
Each time the patient attends they are registered on the PAS
When the patient arrives in for their appointment they are registered to the relevant clinic on the PAS with
the clerical staff confirming the patient’s details (e.g. mobile phone
number for text reminders) and outlining the department policies.
Resource: Clerical staff
Av Task Time for return patient registration = 12.6 seconds
Resource: Clerical staff
Av Task Time for new patient registration = 62.36 secondsNew Reg
Return Reg
A front sheet is printed out on the first registration (outline of appointments in
hospital and personal details) and physiotherapy notes are made up which
include the referral, a peripheral or spinal assessment sheet and continuation sheets
for progress notesThe clerical staff then walk to deposit the
notes in the main physiotherapy outpatient department
Resource: Clerical staff
Av Task Time for each set of new notes = 41.52 seconds
From C (a) Patient
Attendance
PAS
PhysiotherapyNotes
PT NOTES
C (c) REGISTRATION
Figure 4.8 Registration
81
C (b) 2DNA automatically registered on the
PAS
C (b) 1Patient does not
attend
C (b) 3First
appointment
YES
C (b) 4The patient makes
another appointment within
two weeks
NO
NO
YES
C (b)PATIENT NON-ATTENDANCE
C (b) 5Patient rings to cancel
C (b) 8This is the third
consecutive cancellation recorded
on the PAS
C (b) 7Immediate
rescheduling
To D Discharge
To C1 Patient
Attendance
YES
NO
YES
NO
From B (a) Booking
PAS
C (b) 6Patient self-
discharge
NO
YES
Figure 4.9 Patient Non-Attendance
82
Figure 4.9 illustrates the process for non-attendance. Overall the patient
non-attendance block of the process seems to work well with the
department receiving automatic reports from the IT department on the
number of cancellations and DNAs on a monthly basis and actions taken to
try to improve the rates. Of note, when it comes to retrieving the notes of
patients who have cancelled and not made subsequent appointments the
process involves the physiotherapist going through all of his/her active
notes and subsequently removing the notes of these patients; a manual
process (see step E7 in figure 4.11) (I11).
83
D - DISCHARGE AND REFERRAL ONWARDS
From ATriage and
Referral Management
D1Community Referral?
D5Identify community care area
D6The patient is
informed
YESD3
Print off relevant details from EPR
D2Local Hospital Referral?
NO NO
To A Triage Or B (a) Booking
YES
D4Post
To D Discharge
To D Discharge
From C (a)Patient
Attendance
From C (b)Patient Non-Attendance
D9Referrals/
physiotherapy notes are filed away in the current year archive
NOTE THERE IS NO ENTRY
MADE ON THE PAS OR EPR THAT THE
PATIENT HAS BEEN
DISCHARGED
D8Patient Discharged is
written on the referral/
physiotherapy notes
PhysiotherapyNotes
EPR
PhysiotherapyReferral
PhysiotherapyReferral
PT REF
PT NOTES
D7Details entered into community
databaseCommunity
database
Community database
COMM DB
Figure 4.10 Discharge
84
Figure 4.10 illustrates the process carried out when the patient is to be
discharged from physiotherapy. The patient may be referred to their local
hospital or community care area at the point of triage. This is a paper-based
process (I9). The patient is informed that they have been referred to their
community care area but not if referred to their local hospital so there is no
standard process. There is no entry made on the EPR or PAS that the
patient has been discharged. This is only written on the physiotherapy
referral/notes which are stored in the physiotherapy department and not
accessed by others. An entry on the PAS or EPR would allow internal
referrers to see that the patient has completed their physiotherapy (I11).
85
E 1Physiotherapists file away return patient
notes daily
E 2Clerical staff file away
new patient notes daily
E 3Clerical staff retrieve
notes for patients due to attend the next day
daily
E 4Clerical staff archive notes that have been
discharged as time allows
Resource: Clerical staff
Av Task Time for one set of notes = 10.44 seconds
Done in batches
Resource: Clerical staff
Av Task Time for one set of notes = 16.3 seconds
Done as batches
E RETRIEVING AND
FILING PHYSIO NOTES SEE DOCUMENTS
E 5Notes are retrieved for medico legal reasons
from active files, current year and/or old
archives when requested
E 6Notes of DNAs held in DNA box for 2 weeks
then discharged if appointment not made
E 7If appointment
cancelled and no follow-up needed notes are
removed from the active notes
immediately and discharged
E 8Notes of Cancels left in
active files and then discharged if
appointment not made within 2 weeks
To C (b) Patient Non-Attendance
To C (b) Patient Non-Attendance
To C (b) Patient Non-Attendance
Active notes are stored by clinic code alphabetically
Active notes are stored by clinic code alphabetically
PhysiotherapyNotes
PT NOTES
Lists for each clinic
CLIN LIST
Current Year Archive
CURRENT
DNAs BoxDNAs Box
DNA
Old Archive
OLD
Active Notes
Clinic Name Alphabetically
ACTIVE
Resource: Physiotherapist
Av Task Time for one set of notes = 10.4 seconds
Done in batches
Figure 4.11 Retrieval and Filing of Physiotherapy Notes
86
As outlined in Figure 4.11 a significant amount of time is spent by both the
clerical and physiotherapy staff on the retrieval and filing of notes on a daily
basis (I11). Each set of notes takes approximately 10 seconds to retrieve
(n= 18) and 10 seconds (n = 21) to file away. Archiving notes takes over
16 seconds per set of notes (n = 12).
In figure 4.12 we see that a significant amount of time is taken up
accessing information during the patient attendance; more than 99 seconds
(n = 7) of the physiotherapist’s time each visit is taken up searching for
information to assist the decision-making process or give to the patient to
aid recovery; exercise sheets, outcome measures, x-ray and scan results
and other correspondence (see table 4.6 for further details) (I11). During
the time the physiotherapist accesses this information the patient waits
alone in the cubicle. While it is acknowledged that all steps in this process
add value to the patient in terms of treatment planning and goal setting,
information could be more easily and efficiently accessed.
87
On their first attendance the physiotherapist
takes an extensive history from the
patient
Red flag questions are used to assist in
decision-making/alert the physiotherapist to
extra/particular precautions
Each time the patient attends the physiotherapist documents in the paper physiotherapy notes in the
form of a SOAP (Subjective, Objective, Analysis and Plan) note
Home exercise programmes (HEPs)
are printed off a separate PhysioTools
package if individualised for a
patient or taken from a filing cabinet where they have been pre-
printed
If the Physiotherapists wants to show the patient their x-
ray/scan result as part of management they must leave
the cubicle where they are treating the patient and log
on to the EPR to print this off
A body chart is used to document pain site and
intensity
For Rheumatology patients there is a correspondence
section on the Rheumatology G Drive
where relevant letters and referrals can be viewed to
aid decision making
Outcome measures are often used at the initial visit and subsequently to review
the patient’s progressThose used are mainly patient self-reported
questionnaires and are retrieve in paper based copies from the filing
cabinet as needed
Resource: Physiotherapist
Av Task Time to gather information per patient visit = 99.54 seconds
CLINICAL DOCUMENTATION AND INFORMATION RETRIEVAL
From C1 Patient
Attendance
To D Discharge
To B Booking
CORR
PhysioTools package for HEPs
PhysioTools package for HEPs
EPR
Outcome Measures
Figure 4.12 Clinical Documentation and Information Access
88
The following tables outline the documents and data created and information accessed by the clerical and physiotherapy staff
during the patient’s journey.
Table 4.4 Documents created
Document Daily work list Physiotherapy Referral
Yellow Appointment
Card
Front sheet Physiotherapy Notes including file
made up to hold them
Discharge Letters Report to referrer
Type
Paper EPR Cardboard Paper Paper File is cardboard
Paper E-mail for Rheumatology patients (internal
referrals) Paper to all referrers Telephone calls to all
referrers (?data)
When accessed?
Daily print from PAS for next day
Lifted from printer on referral
Reviewed by physiotherapist
Every attendance
On first attendance
Each time patient attends
Not routinely done Completed once on discharge
Written by physiotherapist and posted internally to
medical records chart room for filing
As needed
Where stored?
Paper is discarded once the clinic date
has passed
In standard folders until appointment
booked In “new patients” box
when appointment booked until patient
arrives in In physiotherapy
notes
With patient In the front of the physiotherapy
notes
In notes storage area as long as
patient continues to attend
In filing cabinets on discharge for 8
years Notes holders are
recycled
Original filed in medical chart Copy filed in physiotherapy
notes
Copy of letters kept in physiotherapy notes
Note made of phone call E-mails kept separately
89
Document Daily work list Physiotherapy Referral
Yellow Appointment
Card
Front sheet Physiotherapy Notes including file
made up to hold them
Discharge Letters Report to referrer
What
used for?
For each physio
to know which patients (whether new or return) are arriving on a given
day. The physiotherapists document any
DNAs or Cancels on the paper worklist?
Details on referral used to decide clinical
priority (triage)
Details from referral transcribed into Excel
spread sheet
Appointment Time
Clinic Code
Physiotherapist’s name
All written on it
Unclear All clinical documentation relating to the
patient
Retrieved for research, audit and
medico legal purposes
To update referrer on patient’s status on discharge
from physiotherapy
No discharge letters sent since Nov 2012 due to
reduced clerical capacity
To highlight concerns to referrer
To give update
90
Table 4.5 Data created
Data
created
Waiting List Excel Spread Sheet -
database of patients waiting
Waiting List Excel Spread Sheet -
of numbers waiting and time waiting
Reports from the PAS
Number of new, return, DNAs and cancels
New and returns per consultant/specialty
Excel spread sheet outlining all
community referrals
Type
Excel
Excel
On-line report run by the IMS
department
Excel
When accessed?
All referrals manually transcribed
into database Accessed if patient rings department
Numbers counted manually and
inserted monthly
Monthly
Monthly
Where stored?
On department drive
On department drive
On department drive
On department drive
What
used for?
To profile patients attending
To confirm referral received and possible length of wait for patients
phoning the department If referral sent on to community or local hospital this is recorded here
To give number of referrals and
numbers in each category of wait to HSE
New and returns needed for HSE
CompStat New, returns, DNAs and cancels needed
at corporate level Used for annual reports, service plans,
business cases
Knowledge of referrals sent out
and demand for community services
To show patient seen in most appropriate setting
91
Table 4.6 Information Accessed
Information Accessed
Home exercise programmes (HEPs)
X-ray/scan result
Further correspondence relating to the patient
Outcome measures
The Evidence Base or clinical guidelines
Type
Paper
EPR Report and image
Scanned letters or letters saved electronically
Paper or soft copy
Paper or soft copy
When accessed?
While the patient is attending
Prior to or while the patient is attending
While the patient is attending
While the patient is attending
In between the first and second patient attendances
Where
stored?
Pre-printed or in most cases individualised and printed from a PhysioTools package
EPR
EPR and specialty drive
Paper based in filing cabinet or electronic on department drive
On-line or paper based in filing cabinet
What
used for?
To give to patient to carry out independent exercise
To aid decision making and treatment planning
To aid decision making and treatment planning
To aid goal setting and determine progress
To aid decision making and treatment planning
92
4.4 Semi-structured interviews
As previously outlined in section 3.4.2 three semi-structured interviews of
key physiotherapy informants who have implemented process
improvements and/or health information technology were undertaken. The
interviewees reviewed the detailed process maps, outlined where
improvements could be made, gave clear suggestions as to what those
improvements would look like and their potential benefits and finally they
gave some advice about possible challenges and how to manage them.
The three experts interviewed confirmed that they were familiar with
process maps. All found the diagrams and notations very clear. The
overview/high level workflow and the documents, data and information
accessed tables were found to be very useful.
Prior to outlining the process improvements suggested at the interviews an
overview of opinions expressed by the interviewees on the process maps
and methodology used is presented.
It was suggested that the diagrams could be used to explain the workflow
to others who do not work in the department under study. They could also
be used in another area or across disciplines as a good starting point for
similar work.
With regard to the methodology used to map the workflow i.e. observation
and validation with staff observed; it was suggested by one of the
interviewees that staff could have been asked to input directly into the
workflow. This is known as a “Kaizen event” in Lean terminology and would
usually involve freeing staff up for 3-5 days to map the process. However, it
was acknowledged that this would be hard to do while maintaining a
service. It was also suggested that ideally the patient’s viewpoint should
be included.
All clarifications that were sought related to the department’s activity and
definitions; the definition of a new patient, the number of new and return
93
patients seen by each therapist daily, the monthly demand and an
understanding of possible reasons that there is a waiting list.
4.4.1 Suggested Improvements arising from interviews
There follows an outline of suggestions for improvement which emerged
from the interviews. These are grouped in the blocks (A-D) outlined in the
high level process map (see figure 4.1).
There was an emphasis on using the functionality in existing systems to
their fullest extent and in particular the use of simple IT methods of
communication such as text messaging and e-mail.
A – Triage and Referral management (Figure 4.4)
In general, comments were that there is too much movement of paper and
people and too many “hand-offs”. There is duplication of work when
transcribing patient details from the printed referrals to the Excel spread
sheet as all details are already contained in the electronic referral. There
could also be a clinical risk in transcribing data from the referral to the Excel
file. The risk of storing all of the referral and waiting list data on a general
drive in Excel was also highlighted. It was queried if this was safe and
secure, how many staff had access and could the file be accidentally
deleted? It was also stated that an Excel file could become corrupt over
time, with many changes being made leading to loss of data. Other issues
with Excel and having several individuals accessing and updating a file is
that there is no way of knowing who updated which parts and there is no
audit trail; this is after all patient data.
Suggested Improvements:
Upgrading the current EPR to allow for everything to be done on one
system (Not Possible).
Clerical staff triaging by giving clerical staff clear guidelines on how to
triage. This would eliminate the movement of paper and people and
reduce the time taken for this part of the workflow even if this
94
continued to be done on paper. However, ideally triaging should be
done electronically (I4).
The accuracy of coding at this point in the workflow was queried and
it was suggested that this should be done at a later point, ideally
discharge. To make improvements to patient outcomes it is important
to look back at the input each patient was given. If coding were to
happen at discharge the input for each of the discharge codes could
be reviewed and this could be used to determine changes required to
service provision or to improve outcomes (I14).
Use of formulae in the Excel file to assist with calculation of waiting
times (see B (b) below).
B (a) – Appointment Booking (Figure 4.5)
The booking of appointments needs to be standardised to ensure efficiency
in the process and so reduce unnecessary waiting for patients. A lot of time
is wasted phoning patients with appointments and in many cases staff do
not received an adequate response.
Suggested Improvements:
The appointment booking process should be standardised (I12).
Clarification of the booking policy regarding booking new patients into
return slot (I1).
Sending an appointment by text and giving the patient an option of
Yes/No to accept should be explored. This still gives the patients the
option to look for an alternative yet eliminates the need for the
clerical staff to do so much ringing (Not Possible).
A short waiters list – of patients who are happy to be contacted at
short notice for those last minute appointments [next day
appointments] could be explored (I15).
95
B (b) – Waiting list data (Figure 4.6)
This involves too much manual counting and too much paper. It was
queried why this process is manual when all of the information needed to
calculate waiting times gathered in the Excel referrals spread sheet and so a
formulae could be used to assist. It was also queried why if the bookings
are carried out in the PAS why this information couldn’t be drawn down
from there? The researcher explained that the referrals are generated in the
EPR (and date stamped with the date of referral) but there is no connection
between the EPR and the PAS that would allow for date of referral (EPR) to
date appointment booked (PAS) to be calculated.
Suggested Improvements:
Waiting list data should be generated electronically. This would
increase the reliability and accuracy of the data. An electronic system
works off an algorithm therefore; there is consistency with calculation
(I4).
C (a) – Patient attendance (Figure 4.7)
Suggested Improvements:
Use a self-registration booth (I10).
Electronic documentation would get rid of make-up of notes (I11).
Self-appointment making booth for return appointments (I16).
Return appointments could be confirmed by text one day in advance
as the current 5 days is too long (I8). The patient should have the
option of replying to this text. The reply can be set up to go to the
department’s e-mail and be checked each morning. Text speak can
be used if characters limited. All texts could be embedded in each
individual patient’s record.
Text messaging for mass cancellation of appointment, for example if
a clinician is sick (Not possible).
96
Stop using appointment cards as patients receive a text message
(I8).
Draw a body chart diagram and scan it in to the EPR to attach to the
patient record (I11).
Take photos for certain evaluations to engage patients and as a
motivator for patients. A photo taken with a mobile phone which can
be uploaded and attached to the patient’s record on the system has
huge advantages (I17).
Using the camera in a tablet or laptop would be very helpful. The
photo could then be uploaded to the patient’s record (I17).
Simple outcome measures could be embedded into the patient’s
record. This is motivating for the patient and helps the
physiotherapist to review progress (I18).
D – Discharge and onward referral (Figure 4.10)
Suggested Improvements:
Clarity around what services are actually available in the HSE is a
challenge. There should be one national database of services. It is
acknowledged that this is a wider issue for the health services than
the department under study (I19).
Have an agreement with referrers that a discharge summary is only
sent if requested (I20).
Links with hospitals and other agencies could be by secure e-mail
communication (taking into account data protection issues) (I9).
4.4.2 Potential Benefits as identified by interviews
The interviewees were then asked to identify the potential benefits of their
suggested process improvements. The benefits are not broken down by
block in the process map (as in many cases they apply across the
continuum of the process map) but rather how they relate back to the
97
quality aims outlined by the IOM (2001) and those outlined by the HIQA
standards (2012) whereby the patient is at the centre and the care provided
is safe, timely, effective, efficient and equitable with IT and information
enabling improvements.
Overall the benefits of electronic recording were identified as
enormous.
The electronic record gives a much better holistic view of patients.
The ability to look back and see the records of patients who
consistently attend assists greatly. If the usual “recipe” doesn’t work
for these patients this may be a good indicator that the patient needs
to be referred onwards.
• Mass cancellation by text saving significant admin time
Reduce hand-offs between staff
Reduce duplication of effort
Clarity of process, roles and responsibilities
Reduce risk of data loss and errors of data entry
Savings on postage – one interviewee said she used to buy 100
stamps per month now she wouldn’t use 100 stamps in 4 months
Savings on purchase of appointment cards - purchased 10,000 cards
about 2.5 years ago and hasn’t used very many of them
Making the most of functionality and systems already available
reduces cost
Stats can be available as needed
Improve accuracy and safety of data
4.4.3 Perceived Challenges as identified by interviews
During the interviews very few challenges were highlighted and in fact the
two interviewees who have undertaken implementation of IT projects were
very positive about this change but did stress the importance of change
management and staff buy-in. The main exception to this was the challenge
98
in determining what services are actually available in the HSE. As outlined
above this impacts more than the department under study.
Two challenges that were specifically mentioned were finding the correct
solutions to electronic triage and documentation and the possibility of
asking staff to take on non-traditional roles such as the suggestion that
clerical staff could triage.
Some key success factors that were highlighted were:
Staff buy-in
A phased approach making small changes
Clarity on benefits
Selecting a clinical champion who is “aware of the mood on the
ground”
The necessity to carry out a stakeholder analysis which should
include patients and referrers
Administration staff may be threatened by any changes so again stressing
the importance of change management. It is important to state the
positives to those who feel threatened; improved throughput of patients,
ensuring the patient is at the centre and reducing/eliminating risks in the
process (for patient and staff).
Finally it is important to understand that there will always be an element of
discord and that sometimes it’s important to just keep focussed.
4.5 Focus Group
Before presenting the results of the focus group the researcher would like to
outline again the overall goals, of any process improvement, that were
agreed at the focus group. As outlined in section 3.4.3 these goals were
presented as a starting point by the researcher at the beginning of the focus
group and participants were encouraged to add/remove any they didn’t
agree with. No changes were made.
99
Goals:
Improve the patient journey and the importance of keeping the
patient at the centre
Boost staff morale
Reduce non-value added activities, for example, waiting, duplication
and movement
Reduce non-clinical steps for the physiotherapists
Improve ease of access to information – both when the patient is
present (to review previous notes) and to review outcomes and carry
out research
The methodology used for the focus group is outlined in section 3.4.3.
Nineteen improvements were suggested which the participants
subsequently prioritised. The top 10 items are outlined in table 4.7 on the
following page.
100
Table 4.7 Top Ten Suggested improvements identified at the focus group
Suggested improvements identified at the focus group
1. Automatic printing of the "Front sheet" from the PAS for new patients should stop as the information contained therein is not used for anything (I6)
2. Clerical staff to give physiotherapy notes directly to new patients and ask the patient to give them to the physiotherapist to avoid excessive walking (I21 )
3. Edit the text message for each clinic (on OPRS) to ensure the essential details required by the clerical staff at registration are on the text (I8 )
4. Triaging of referrals on the PAS (I4 )
5. Standardisation of the process of actually ringing the patients and booking their appointments on the PAS (I12)
6. Filtering of patient calls by extending the functionality used on the current phone system (I3)
7. Using the PAS for triage would allow for direct booking of appointments from the waiting list (I4 )
8. Electronic clinical documentation on the EPR (I11)
9. If a patient rings looking for an appointment and no physiotherapy referral has been received in the physiotherapy department but the patient has obviously had a recent appointment with the consultant (this can be seen on the PAS) generate a physiotherapy referral and offer the patient an appointment (I13 )
10. Electronic community/local referral (I9)
As outlined in table 4.7 there was an emphasis on (1) simplifying (2)
reducing steps staff need to take and (3) steps in the process that don’t add
value to the customer (4) standardising processes and (5) more extensive
use of the current IT systems.
During the focus group an unexpected energy among the staff involved was
observed, with much discussion and teasing out of ideas. Of interest, it was
not specifically the IT staff that suggested the possibilities of more
extensive use of existing IT systems.
During the regrouping session there was a significant amount of discussion
and some healthy conflict about some suggestions and their feasibility. For
example, the idea that the referring consultant could refer directly to the
101
community, suggested by one participant, rather than referring to the
internal physiotherapy department was discussed at length. This would
reduce the steps the referral (and the patient) goes through to get to the
community physiotherapy services and would ensure the patient is seen in
the most appropriate setting. It was suggested that this would involve
significant training, change management and the group determined it was
best to stay within the locus of control initially.
Perceived benefits outlined at the focus group involved reducing the number
of steps and hence the time frame to complete processes all of which would
indirectly impact on the time patients have to wait for an appointment and
the time the physiotherapist spends in the cubicle with the patient on direct
patient care. Other benefits related to the introduction of electronic clinical
documentation and included (1) access to the patient’s previous records (2)
data accuracy and more reliable profiling of patients (3) reduction in paper
with associated costs and environmental impact.
All benefits relate back to the quality aims outlined by the IOM (2001) and
those outlined by the HIQA standards (2012) whereby the patient is at the
centre and the care provided is safe, timely, effective, efficient and
equitable and IT and information are used to enable improvement.
Some fear was expressed about getting rid of all paper when electronic
clinical documentation was discussed and the importance of having a
contingency plan in the event of systems going down. Otherwise no other
challenges were highlighted.
Some ideas that were not suggested during the focus group but were noted
as possible improvements by the researcher during the observation phase
were: (1) a system similar to “Choose and Book” in the UK whereby the
referrer can book the patient directly into a physiotherapy appointment slot
(I22), (2) asking patients to complete outcome measures prior to seeing the
physiotherapist (as many are self-reported) (I23) and (3) the use of
102
computerised clinical decision support (I24) with electronic clinical
documentation.
Some comments were made by participants when they returned their
prioritised list; one participant stressed that she didn’t believe that
electronic clinical documentation would reduce time the physiotherapist
spent on documentation, some participants prioritised what they felt were
“quick wins” for staff and the patients.
A few gaps were noted in the workflow by the researcher and by
participants at the focus group. These are outlined as follows:
Time spent calculating waiting list times
Time spent by clerical staff ringing and booking patients
Is community or local referral recorded on the referrals spread sheet?
YES
Is the fact that an appointment is given to a patient ever recorded on
the referrals spread sheet? NO this is captured as an appointment
allocated on the PAS
If the patient is late what happens? One participant suggested it
depends on many factors; clinical need, how late, clinical staff on the
particular day
4.6 Conclusion
The methodology used in this study assisted in answering the research
questions. The question of which process improvement methodology to use
was answered through the literature review with the researcher identifying
a process improvement methodology and tools based on the principles of
Lean Thinking. The baseline data, process mapping, interviews and focus
group all answered the questions as to which processes should be improved
and what those improvements could look like. The literature review,
interviews and focus group outlined the potential benefits and some
perceived challenges of the suggested improvements.
103
A more detailed discussion on how this methodology assisted in answering
the research questions will be outlined in the next chapter. As will be seen
there was significant overlap in the suggested improvements that emerged
from the interviews and focus group.
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CHAPTER 5
ANALYSIS AND DISCUSSION
5.1 Introduction
This chapter will now revisit the research questions and give more detail on
answers this research has provided. It must again be acknowledged that the
scope of this research did not involve implementation of the suggested
improvements. However, some suggested improvements have been
progressed and others are planned (section 5.4). Measurement of the
impact of improvements that have been progressed (Figures 5.2 to 5.4) and
those that will take place in the future will need to be continuous.
5.2 Research questions
Main Question (MQ):
How can processes be improved in a physiotherapy outpatients
setting?
Sub questions:
What process improvement methodology is appropriate to apply in
the physiotherapy outpatient setting? (SQ1)
Which processes should be improved? (SQ2)
How should processes be improved? (SQ3)
What are the potential benefits of any suggested improvements?
(SQ4)
What are the perceived challenges of any suggested improvements?
(SQ5)
5.3 Findings
As outlined in chapter 4 the methodology used in this study assisted in
answering the research questions posed. The answers to the sub-questions
will be presented first before returning to the main research question.
105
5.3.1 What process improvement methodology is appropriate
to apply in the physiotherapy outpatient setting? (SQ1)
In order to answer the overall research question, the researcher needed to
first look to the literature to determine which process improvement
methodologies are prevalent in healthcare and which methodology and tools
would be appropriate for use in the study setting.
From the literature review the researcher identified a process improvement
methodology and tools based on the principles of Lean Thinking as the best
fit for the study setting. Lean Thinking principles are simple to understand,
yet are very powerful at exposing waste. Before commencing this research,
issues of waste, lack of standardisation and the need for improved efficiency
due to reduced clerical capacity (section 1.1) were identified by the
researcher. In section 2.3.1 we learned that Lean Thinking as a
methodology is often selected where an organisation values visual
improvement along with positive changes in speed and efficiency. The focus
of Lean Thinking is the process and visualisation of the process. The
customer (patient and staff) is placed at the centre and the emphasis is on
the elimination of any steps that do not add value (waste) from the
customer’s perspective. Data which is practical and meaningful and does
not require complex statistical analysis is used. Staff engagement is crucial.
The researcher then chose the tools from the literature that appeared to be
the most applicable to the research questions and context; process
mapping, interviews and focus group. All of these aspects fit clearly with the
aims of quality outlined by the IOM (2001) and those outlined nationally in
the HIQA standards (2012).
The Six Sigma methodology focusses on problem solving and involves more
extensive statistical analysis than was required for the study context and
the researcher did not think this methodology was appropriate in the study
setting (section 2.3.2). The PDSA cycles are learning cycles and are
appropriate for use for small tests of change (section 2.3.3). As
improvements progress through various iterations the PDSA methodology
106
will be applied to continuously improve any solutions implemented. It was
not, however, identified as an appropriate methodology to answer the
research questions and determine how processes could be improved in the
first instance.
5.3.2 Which processes should be improved? (SQ2)
The recommendation to collect baseline data (Fillingham, 2008; McGrath, et
al., 2008) both to highlight, where improvements are required and to
determine, if any change is indeed an improvement assisted in answering
the question of which processes need to be improved. With implementation
of improvements it would be hoped that there would be an improvement in
throughput, waiting times, paper costs, notes retrieved and filed and the
number of calls unanswered and this will be closely monitored. It would also
be hoped that the time taken to complete processes and the number of
steps involved could be reduced.
Process mapping, the interviews and the focus group also assisted in
answering the question of which processes should be improved (SQ2). Table
5.1 outlines the processes that should be improved as identified from the
process mapping, interviews and focus group.
Table 5.1 Which processes should be improved?
Which process? Relevant process map and
narrative
Suggested
Improvement Code
There is no agreement as to
when new patients can be
booked in to return slots.
Clerical staff say 1 day in
advance whereas
physiotherapists say 3 days in
advance
4.5
Step B(a)8
I1
No standardisation in use of
notations on body chart
4.12 I2
Unanswered phone calls Across full patient journey I3
107
Paper trail and staff
movement involved in Referral
Management & Triage
4.4
Steps A1 to A11
I4
Counting waiting list manually 4.6
Steps B(b)1 to B(b)5
I5
Printing front sheet which is
not used for anything
4.7
Step C(a)6
I6
Use of yellow card for
registration
4.7 I7
Text message reminder sent 5
days in advance of
appointment
4.7
Step C(a)1
I8
Paper based referral onwards
on discharge
4.10 I9
Registration process 4.8 & 4.7
(Steps C (a) 4 & C (a)9)
I10
Paper based documentation,
specifically the retrieval and
filing of notes and access to
information
4.11 and 4.12 I11
No standardisation of the
actual process carried out by
clerical staff when ringing
patients and booking an
appointment on the PAS.
4.5
Steps B(a)1 to B(a)5
I12
Process for dealing with
patient queries is not
standardised or patient
centred
4.6
Steps B(b)6 to B(b) 12
I13
Coding at point of triage 4.4
Step A8
I14
108
Process mapping highlighted the complexity of the processes, that there are
multiple repositories of patient information (figure 4.2) and a significant
number of documents and data are produced in the department (tables 4.4,
4.5 and 4.6). The processes need to be simplified and the number of
repositories could be reduced (I11).
Process mapping also demonstrated the need for standardisation of some
processes and this was further highlighted by the interviews and focus
group. Examples are the use of notations on the body chart (I2), the policy
for booking new patients into return slots (I1), the actual process for
ringing patients and booking appointments (figure 4.5) (I12) and the
process that occurs when a patient rings the department with a query
(figure 4.6) (I13).
In particular, capturing the existing process of booking new patients into
return slots showed up inconsistencies in the implementation of the current
booking policy (I1), and allowed it to be corrected immediately. The effect
of this on waiting lists was significant and immediate – see section 5.4.
The three stages of application of the process improvement methodology
showed without a doubt that the concurrent use of paper-based systems (I9
& I11) and disparate IT systems is resulting in duplication of effort (I5) and
inefficiencies (Unertl, Weinger and Johnson, 2006).
The referral management and triage process (figure 4.4) (I4) and patient
attendance (figure 4.7) involve a significant amount of transportation of
people and paper and some non-essential activity (I6) and duplication.
The text message reminder was sent 5 days in advance of an appointment
which was felt to be too early (I8). Clerical staff rely heavily on the details
written on the yellow appointment card to complete the registration process
and if the patient misplaces this card the registration process takes much
longer (I7).
During the observation the researcher witnessed a significant number of
interruptions from phones yet 20% of calls remain unanswered and many
109
calls were put on hold (waiting) (I3). These interruptions led to variation in
the time taken to complete some processes, for example, registration
(figure 4.8) (I10).
As outlined in section 2.3.1 in Lean Thinking all steps should add value to
the customer’s journey. Referring back to the 7 types of waste we can see
there is substantial waste in terms of overproduction, waiting,
transportation, nonessential activity and variation.
Finally these three stages also suggested that the current processes in use
for the IT systems could be improved and lead to more extensive use of the
systems.
5.3.3 How can processes be improved in a physiotherapy
outpatients setting? (SQ3)
This section looks at the “how” or in other words what improvements might
look like.
The case studies in the literature review (section 2.6) outlined some
improvements that have been implemented elsewhere. Section 2.8 outlined
process improvements through the introduction of IT in physiotherapy. The
literature review gave the researcher several ideas of what improvements
might look like, which included
More efficient referral pathways
Self-registration kiosks
Electronic clinical documentation
and associated clinical decision support
Through the semi-structured interviews with key informants and through
the focus group several ways to improve processes also emerged. All ideas
outlined had a focus on the patient and staff as customers of the service
either directly or indirectly. An overview of suggestions that emerged from
the interviews and focus group is presented in figure 5.1 in the form of a
Venn diagram to demonstrate where there was overlap.
110
Some of the suggested improvements are outlined a little further here.
Electronic triage refers to changing the current paper-based process of
triaging referrals to on-line triaging (I4). This would eliminate the excessive
movement of paper and staff in the current process. Text messaging refers
to a suggested change to the current text message patients get from a
reminder 5 days in advance to 2 days in advance and also to change the
message to include details that would be useful for the registration process
in cases where the patient misplaces their yellow card (I7&8). Gathering
waiting list data electronically would increase the accuracy and reliability of
the data (I5). Electronic referral onwards to community care or other
hospital via secure e-mail would improve the efficiency of the current
process and ensure necessary information is received at the receiving site
(I9). Standardisation of the policy for booking new patients into return slots
(I1) and the process for actually booking appointments ensures all patients
are treated in an equitable manner and there are no unnecessary delays
(I12).
111
Figure 5.1 Venn diagram of suggested improvements from interviews and focus group
Electronic Triage I4
Text Messaging I8
Electronic wait list data I5
Electronic Documentation I11
Electronic Referral onwards I9
Standardise process of ringing patients with
appointment s and booking
on PAS I12
Self-Registration I10
112
5.3.4 What are the potential benefits of any suggested
improvements? (SQ4)
The literature review, interviews and focus group all outlined the potential
benefits of implementing improvements.
An overview of the benefits highlighted from the literature review includes:
Patients getting more time with providers
More timely results
Improved staff morale
Improved customer satisfaction
Reduction in errors
Improvement in outcomes
Throughout
Safety
Overall quality of care
Those highlighted through the interviews and focus group were more
specific to the context of the study. For the focus group an attempt was
made by participants to stick to the overall goals outlined. The benefits are
summarised below in no particular order:
Easier access to patient information and previous physiotherapy
notes
Reduced time to triage referrals
Reduced time from referral received to waiting list to appointment
Reduced paper – cost and environmental
Improved data accuracy as not manually collated
Reduced delays for patients
Improved customer service – patient and staff
113
All benefits impact on the quality of care provided: effectiveness, timeliness,
efficiency, equity, safety and most importantly patient centeredness. A draft
benefits realisation plan is outlined in Appendix H.
5.3.5 What are the perceived challenges of any suggested
improvements? (SQ5)
Challenges outlined in the literature (section 2.9) were summarised as the
general characteristics of healthcare, the need for staff involvement,
importance of data to demonstrate the need for improvement and if a
change is indeed an improvement and visible leadership. These or other
significant challenges did not emerge during the interviews and focus group
except for the need for staff buy-in from start to finish (interviews) and the
fear of a completely paperless department (focus group). However, those
highlighted in the literature review must be acknowledged and the need for
a clear change management strategy is evident. How some of these
challenges have been or will be addressed will be discussed in section 5.4.4.
Perhaps these methods were not the most appropriate way of determining
possible challenges despite the literature suggesting them as a methodology
and further context specific challenges will most likely arise as
improvements are progressed (Victorian Government report on using data
for quality improvement, 2008).
5.3.6 Conclusion to Research Questions
The main research question of how processes can be improved in
physiotherapy outpatients setting has been answered through the sub-
questions which have determined which process improvement methodology
could be used (SQ1), which process should be improved (SQ2) and what
this could look like (SQ3), the potential benefits (SQ4) and challenges of
making any suggested improvements (SQ5).
There is more detail on the proposed improvements and their
implementation in section 5.4.
114
5.4 Progress and Plans for Suggested Improvements
In this section some detail of the progress to date and plans for the
improvements outlined is provided.
5.4.1 Progress made to date
As noted in section 4.3, when process mapping the booking of new patients
into return slots, misunderstandings became apparent, the policy was
clarified and agreement reached to adopt the clarified policy. This occurred
in the 3rd week in January 2013. By getting an agreement on the booking
policy (I1) an improvement in numbers waiting and waiting times was
immediately evident – see figures 5.2 and 5.3 which show no patients
waited for the 3 months following the improvement in the two specialties
under study. Figures 5.3 and 5.4 show the number of weeks waiting for the
same patient cohort. These changes occurred with no increase in staff
resources or decrease in referrals to the physiotherapy outpatient service.
Comments from patients on the “comment cards” have also outlined that
patients who attended in the past have been surprised that they were called
for their appointment so quickly. If this short waiting list continues there will
be no need to look at “the short waiters” option (I15).
The number of new and return patients seen per month has also increased
with the clarification of the booking policy. The average number of new
rheumatology patients seen per month increased to 38 (from 27) and the
average number of return patients to 132 (from 104). The average number
of new orthopaedic patients seen per month increased to 162 (from 140)
and the average number of return patients to 452 (from 422) (see table
4.1).
115
0
10
20
30
40
50
60
70
80
Jan
-12
Feb
-12
Mar
-12
Ap
r-1
2
May
-12
Jun
-12
Jul-
12
Au
g-1
2
Sep
-12
Oct
-12
No
v-1
2
De
c-1
2
Jan
-13
Feb
-13
Mar
-13
Ap
r-1
3
May
-13
Jun
-13
Jul-
13
Figure 5.2 Number of patients waiting for a rheumatology physiotherapy appointment Jan 2012 – July 2013
0
10
20
30
40
50
60
70
80
Jan
-12
Feb
-12
Mar
-12
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r-1
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-12
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g-1
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-12
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-12
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v-1
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De
c-1
2
Jan
-13
Feb
-13
Mar
-13
Ap
r-1
3
May
-13
Jun
-13
Jul-
13
Figure 5.3 Number of patients waiting for an orthopaedic physiotherapy appointment Jan 2012 – July 2013
The reason for there being 23 patients on the orthopaedic waiting list in
June (figure 5.3) with a 2 week wait (figure 5.5) was due to this service
being reduced by one member of staff due to a period of annual leave with
no backfill. Once the staffing level was restored there was no waiting.
Booking
Policy
Clarified
Booking
Policy
Clarified
116
2
1
4 4
5 5
8
6
8
7 7
6
4
0 0 0 0
2
1
0
1
2
3
4
5
6
7
8
9
Jan
-12
Feb
-12
Ma
r-12
Ap
r-1
2
Ma
y-1
2
Jun
-12
Jul-
12
Au
g-1
2
Sep
-12
Oct
-12
No
v-1
2
De
c-12
Jan
-13
Feb
-13
Ma
r-13
Ap
r-1
3
Ma
y-1
3
Jun
-13
Jul-
13
Figure 5.4 Number of weeks patients waited for a rheumatology physiotherapy appointment Jan 2012 – July 2013
Figure 5.5 Number of weeks patients waited for an orthopaedic physiotherapy appointment Jan 2012 to July 2013
6 week HSE target
6 week HSE target
117
The body chart notations are now standardised in preparation for
electronic clinical documentation (I2)
The script for the answering machine message and how phone calls
can be filtered has been implemented (I3). This has led to a
reduction in unanswered calls. This has, however, led to an
unintended consequence of a small number of patient queries being
filtered to the manager’s phone as this can be chosen as one of the
options.
The IT department has given a demonstration to clerical and
physiotherapy staff of an on-line triaging system in the EPR and PAS
(I4). This system will allow for on-line triage, direct booking of
appointments and automatic reporting of waiting list data (I5). The
current format needs to be changed somewhat but the initial
response from staff was very positive. When this is implemented
triaging and the booking of appointments will be standardised by the
introduction of IT
The front sheet is no longer printed which means the elimination of
printing of 5,500 sheets of paper each year (across all the
physiotherapy outpatient services). This has also allowed the
reception area to amalgamate their printer use into one printer with
two trays (previously there was two printers with two trays in each)
which was an unexpected benefit and will reduce toner costs (I6)
The text message has been updated to include the therapist’s name,
information that is useful to the clerical staff at the point of
registration and which could eliminate the need for the yellow
appointment card in the future (I7)
The text message reminder has been changed (in line with the
changes to the booking policy) from 5 to 2 days and the patients will
also get a text message as confirmation when their initial
appointment is made (I8)
118
The IT staff have given a demonstration to physiotherapy staff of a
body chart embedded in the current EPR and the initial response is
that it is a very good solution – see screenshot in figure 5.6 below
This improvement relates to (I11) or the preparation for Electronic
documentation (see section 5.4.2 below)
Figure 5.6 Body Chart in Cerner Millenium EPR
5.4.2 Plans for the future
There are plans to pilot an electronic community referral with one
community area in the coming months – the community referral form
is already built in the EPR and a feasible secure e-mail solution has
been identified (I9)
A self-registration pilot is taking place in another section of the
hospital but it is unclear at this stage if this will be rolled out to other
departments. A similar project has been successfully piloted in
another large acute teaching hospital (I10)
A. 4 notations
1. Numbness = dots
2. Paraesthesia = xxx
3. Pain = shading
4. Tick (to clear joints ie denotes no symptoms at ticked joint)
B. Free text pain descriptor (e.g. agonising, aching - limit to 25 characters)
C. Drop down menu for 2 items
1. NRS (numerical rating scale = 0 - 10) (i.e. pain intensity)
2. intermittent/constant (i.e. frequency of pain)
119
Complete electronic clinical documentation on the EPR is progressing
and all forms currently used are gathered, common fields across all
forms identified and conditional logic outlined (I11)
A future process map might look something like Figure 5.7 and key
repositories like Figure 5.8
ALL referrals are placed on the EPR and referrals do not print so
there is no waiting list folders or new referrals box
Triage occurs on-line on the EPR /PAS and there is no requirement for
a separate referrals database
Appointment booking occurs directly on to the PAS by having EPR
and PAS open simultaneously
Waiting list data required for HSE CompStat is retrieved electronically
Community referrals are completed on the EPR and are e-mailed to
the relevant community care service via a secure e-mail solution
There is no need for a separate database to be maintained of all
patients referred to the community as this information will be
available electronically
Text message reminders are used for appointment confirmation as
well as reducing the need for (while not eliminating) the need for
yellow appointment cards
Patients self-register their attendance for all appointments – there is
some debate about whether this could be used for new appointments
or only return. It is also likely that not all patients will be happy to
use the self-registration system
Electronic clinical documentation on the EPR and available on a
mobile device allows for clinical decision support to be embedded and
for the clinician to view the patient’s results without leaving the
cubicle/in conjunction with the patient
120
Patients can complete self-reported outcome measures prior to
seeing their physiotherapist
Audit and research are more easily carried out
DNA and cancellation reports will continue each month but there will
be no need for the physiotherapists to retrieve the notes of patients
who cancelled and did not make another appointment as all notes will
be on-line
Discharge summaries will be available on the EPR to close the loop
and as a reference point for repeat referrals
The archive of physiotherapy paper notes will need to be maintained
in the interim
The EPR and PAS will become the main repositories leading to a
significant reduction in paper use
121
The clerical staff view the EPR “triaged patients” screen and the PAS booking screen simultaneously on the
computer
Referrals triaged on EPR (online) by the physiotherapist
(no paper prints)
ALL Referrals placed on EPR
Patients are phoned and their appointments are booked on PAS
simultaneouslyCommunity or local hospital
referral?
YES
Online community referral is completed
and e-mailed to relevant area by secure
Text sent to patient on the evening their appointment is booked and again 2 days in advance of their appointment
as a reminder
Waiting List data is retrieved automatically from the PAS
When the patient attends they self-register for all appointments
While the patient attends the physiotherapist all clinical documentation is recorded on a mobile tablet device which
has embedded clinical decision support and also allows access to blood results, x-rays, scans in the cubicle with the
patient
When the patient attends they complete self-reported outcome measures on a mobile device when in the waiting
room before they see the therapist
NO
Audit and Research are more easily carried out as all relevant information is in a structured format on the EPR and is retrievable
Community referral data is retrieved
automatically from the EPR
DNA and cancellation reports are available as before based on no registration on PAS
When the patient is discharged a discharge summary is completed to close the loop from referral to discharge
Figure 5.7 Possible Future Process Map
122
PAS
PhysiotherapyNotes
EPR
Monday
New Referrals Box
PhysiotherapyReferral
PhysiotherapyReferral
PT REF
Referrals database
Referrals database
Old Archive
Waiting List folders
Waiting List folders
Lists for each clinicLists for each clinic
Active Notes
Clinic Name Alphabetically
Current Year Archive
DNAs BoxDNAs Box
YellowAppointment
card
ConsultantCorrespondence to GP
ConsultantCorrespondence to GP
PT NOTES
APPTCARD
WLFOLDER
Community database
Community database
COMM DB
REFSDB
NEW REF BOX
ACTIVE
DNA
CORR
CLIN LIST
OLD
CURRENT
KEY REPOSITORIES
Waiting ListNumbers
Waiting ListNumbers
WL NUMBERS
DB
Figure 5.8 Possible Future Key Repositories
123
5.4.3 Suggested improvements that cannot be progressed or
have not been progressed to date
Through discussions with the IT department it has emerged that allowing a
reply to the text messages is not possible and there are no plans to
introduce this functionality (suggestion from interviews).
The suggestion by one of the interviewees that adding a physiotherapy code
to the patient’s record at the point of discharge rather than as it currently
happens at the point of triage is an interesting one (I14). The European
Core standards of physiotherapy15 do specify that a physiotherapy diagnosis
should be added to the patient record but they do not specify at which point
this should be done. However, it is acknowledged that to use clinical
decision support and aid treatment planning adding the physiotherapy
diagnostic code early on in the process would be advised.
Table 5.2 outlines some of the other suggested improvements outlined at
the focus group and interviews that have not been progressed to date.
Table 5.2 Suggested Improvements not yet progressed
Suggested Improvement
Relevant process map
and narrative
Suggested
Improvement Code
Have a short waiter’s list Figure 4.5 I15
Install a self-appointment making
booth
Figure 4.5 I16
Take photos over time to
demonstrate patient progress
Figure 4.12 I17
Embed outcome measures in the
patient’s record (links to electronic
clinical documentation)
Figure 4.12 I18
Clarity around what services are
actually available in the HSE
Figure 4.10 I19
15 http://www.physio-europe.org/download.php?document=71&downloadarea=6
124
Agreement with referrers to give a
discharge summary only if
requested
Figure 4.10 I20
Clerical staff to give notes to the
patient to avoid excessive walking
Figure 4.7 I21
A process similar to Choose and
Book
Figure 4.5 I22
Patients completing self-reported
outcome measures prior to
attendance
Figure 4.7 I23
Computerised Clinical Decision
Support
Figure 4.12 I24
125
5.4.4 Proposals to address challenges
As outlined previously staff involvement, a focus on the customer and data
are key to the success of process improvement. Improvements are more
likely to be sustained if staff have been involved and change has been
successfully managed. As has been seen in this research, data can be used
to convince staff that improvement is needed and that a change is indeed
an improvement. To date physiotherapy department and IT department
staff involved in the focus group will be key to the realisation of any
improvements and the associated benefits and it will be important to
engage with them on a continuous basis. A continued focus on the customer
and how any change impacts is essential, both now and in the future.
5.5 Conclusion
This chapter outlined how the methodology used answered the research
questions. Which processes should be improved was highlighted along with
suggestions as to how this could be done. The benefits of any suggestions
were then outlined along with some challenges to any implementation. The
next chapter outlines recommendations for future research and some of the
limitations of this study.
The mixed methods approach applied in this research, with collection of
quantitative and qualitative data, adds to the validity of the results. When
improvements are carried out in the future having all of this data would
assist greatly in monitoring improvement.
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CHAPTER 6
CONCLUSION
6.1 Introduction
A process improvement methodology and tools based on Lean Thinking
principles was successfully used to determine how processes could be
improved in a physiotherapy outpatients department. Ample opportunities
for process improvement in the physiotherapy outpatients department
under study emerged. Staff engagement in determining opportunities for
process improvement and the priority in which these opportunities should
be explored has assisted greatly with staff buy-in. It will be important that a
phased approach is used going forward as too many changes can exhaust
staff (Azad, 2012). Availability of data on an on-going basis, preferably
electronically (for accuracy and credibility) will be crucial.
6.2 Recommendations for Future Research
Any future work should involve continuous review of the baseline data as
the suggested changes are implemented. It will be necessary to monitor
patient throughput, which has already increased, and the impact this
change has on the number of notes that require retrieval and filing on a
daily basis and the impact on storage facilities.
As outlined in the literature, patient engagement and involvement is
important in any process improvement and any change should be seen as
valuable to the patient (Locock, 2003 (b); Ben-Tovim, Dougherty, O’Connell
and McGrath, 2008; Azad, 2012). McGrath, et al. (2008) outline how often
the most innovative solutions come from patients so engagement of
patients with process improvement initiatives through focus groups or
surveys would be a good idea for future work. It is acknowledged that the
department under study does have a comment card system and makes
changes suggested by patients as appropriate. However, the patient
127
experience of any improvements will need to be assessed further
(Mazzocato, et al., 2010).
Staff satisfaction should also be assessed and has not been extensively
measured (Holden, 2011).
Communication flows and methods of communication – to community, to
other referral sources, to patients, to referrers should be looked at more
thoroughly. It will also be useful to look at any unintended consequences of
improved processes e.g. more efficient referral onwards to the community
could lead to a backlog in that system. Finally, if processes are streamlined
and information technology is introduced there will be possibilities for
further research into other quality aspects such as patient outcomes from
various treatments.
6.3 Study limitations
This study had a few limitations.
This was a single case study and a comparative study with another
similar department may have been useful and may have increased
the scalability of the results to other physiotherapy departments.
There was no external expert guiding the process (Mazzocato, et al.,
2012). However, as can be seen from the study by Scott, et al.
(2011) process improvements led internally are often more
successful. Also the literature was reviewed, guidance was received
from the researcher’s supervisor and experts were consulted. Since
January 2013 the researcher has also undertaken a 6 day course on
leadership and quality improvement. However, the main focus of the
course was PDSA cycles.
It must be acknowledged that the department under study has
limited experience in this area. Trinity Health spent seven years
training physicians and other staff in the use of improvement tools,
data use and process maps (Brokel and Harrison, 2009). Despite this,
128
as outlined by Locock (2003 (b)) much of it is common sense and as
highlighted extensively in the literature having the staff who work on
the frontline and best know the processes and where improvements
can be made is key. Staff easily understood the process maps at the
focus group and embraced the challenge of seeking out opportunities
for improvement with significant enthusiasm.
As outlined in section 2.5.1 consideration should be given to using
more than one type of process mapping.
The Hawthorne effect needs to be acknowledged as the researcher is
one of the managers in the department under study and there is
always the possibility of performance bias in such a situation.
Enthusiasm and the buy-in for the process improvement initiatives
outlined which has been witnessed to date could be down to the fact
that the focus has been on the staff. Some of the comments made at
the focus group and in e-mails to the researcher afterwards would
give some credence to this theory.
“We always knew it was a busy department but it is great to have
this information documented objectively and acknowledged”
“It's great that someone is doing their Masters on this as otherwise
there would never be the time to look at it” This comment concurs
with the comment made by one of the interviewees that a 3-5 day
“Kaizen event” would have been worthwhile but would it have been
possible with service demands as they are?
“It's great to be a part of a group that is willing to look at a problem
and try and conjure some ideas that will improve the patient
experience – it’s very inspiring”.
6.4 Conclusion
This research demonstrated that a process improvement methodology and
tools based on the principles of Lean Thinking can be applied in a
129
physiotherapy outpatient setting to determine how processes can be
improved. Data and staff engagement, including IT department staff, have
to date, and will continue to be key to the success of any initiative.
130
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Appendices
Appendix A: Overview of physiotherapy
Appendix B: Protocol for semi-structured interviews
Appendix C: Consent form
Appendix D: Participant information sheets
Appendix E: Ethics
Appendix F: Key to notations on process maps
154
Appendix A: Overview of physiotherapy
Outpatient physiotherapists treat patients residing at home and aim to achieve the
best possible outcome and provide advice to increase and maintain the patient’s
quality of life and independence.
The main focus of physiotherapy is movement, which is essential for everyday
function. Outpatient physiotherapy involves the assessment and treatment of
muscles, tendons, ligaments, bones, spinal discs, nerves and other structures in
order to restore normal movement. A large part of physiotherapy also focuses on
health promotion.
In the outpatient physiotherapy setting (following consent from the patient for
treatment) the patient receives an initial assessment from an individual
physiotherapist. Depending on the condition or reason for referral the patient may
continue to see the physiotherapist individually, or may be referred on to an
exercise class within the outpatients department or referred to their local
community physiotherapy service (for follow-up in a more appropriate setting).
All information from the initial and follow-up assessments is usually recorded on a
standardised assessment form. Clinical information is recorded in the form of a
SOAP note (Subjective, Objective, Assessment and Plan) and adheres to the
European Core Standards for Physical Therapy, standard 14. The SOAP note was
developed by Dr. Laurence Weed in 1968 as part of the problem oriented medical
record (POMR).
The first stage of an outpatient’s assessment is a subjective examination. During
this exam the physiotherapist will observe the patient’s gait. The physiotherapist
will then take a medical history, followed by a history of the present complaint. This
will involve asking about how the present complaint started, the cause, whether it
has progressed, and whether the patient has had any treatment to date.
The presenting complaint is usually recorded on a body chart. Figure 1.1 is a
standard view of a body chart. It shows an anterior and posterior view of the body
(some charts have left and right views as well). Physiotherapists use symbols to
describe the location and the nature of the pain (sharp, ache), the frequency of the
pain (intermittent, constant) and whether the pain radiates and to where. The
symbols used are not currently standardised among physiotherapists.
155
A number of more specific questions may follow depending on what the presenting
complaint is in order to provide the physiotherapist with as much information as
possible from which to draw up a treatment plan. In addition social history will be
investigated.
Assessment of red flags is a key part of the physiotherapist’s examination to rule
out a more serious condition. While most patients will have musculoskeletal
conditions as an explanation of their symptoms, a small number will have a more
serious underlying issue. These people need to be identified and referred urgently
to a medical specialist. Going through the list of red flags systematically greatly
reduces the risk of missing anything important. There is no substitute for going
through a checklist. An example of a red flag in a patient with a presenting
complaint of low back pain would be a change in bladder and/or bowel. Any
incontinence not previously present or an inability to pass water (retention) is
important and should be immediately reported.
The final question a physiotherapist will ask is what the patient wants from their
treatment; what goals they would like to achieve. Patient involvement is important
to achieve the best possible outcome.
Following this rigorous questioning the physiotherapist will conduct an objective
assessment. The first step of this stage is to observe any discolouration, swelling,
bruising, or scar tissue around the site of injury; this is followed by the
physiotherapist checking for any heat or tenderness in the same region.
The next stage is an observation of movement, both active (patient carrying out the
movement) and passive (physiotherapist manipulating the movement), allowing for
a better understanding of which specific structures are involved in the injury.
Resistive movements are the next stage where movement against resistance is
studied. Based on their findings, the physiotherapist will decide whether there is a
need for a neurological assessment based on reflexes and sensation, in particular
looking for areas of numbness, increased sensitivity, or muscular weakness.
Sometimes the physiotherapist will conduct joint manipulations for more
information. Next, balance and posture might also be observed.
There are many other specialised tests that may be performed for a more specific
study of affected structures, but these vary and are dependent on the findings
throughout the initial stages of assessment.
156
Physiotherapists generally use an outcome measure at the initial assessment and
intermittently at treatment sessions to determine patient progress. An example of
such an outcome measure is the Roland and Morris Questionnaire for patients with
low back pain. However, due to time constraints and difficulties with analysing the
resulting data they are often not used consistently. Standardized outcome
measures have been advocated for use by physiotherapists for many years. They
assist the direction of the treatment plan and enhance communication with patients
(Jette, et al., 2009).
After assessment the physiotherapist will use the information gathered during the
assessment to formulate a treatment plan based on the problems identified and the
objectives the patient wants to achieve through physiotherapy. The problem will be
discussed along with treatment options and recommendations.
Treatment may include some or all of the following: Exercise, mobilisation,
manipulation, soft tissue techniques, electrical modalities and acupuncture. Advice
and education are very important parts of a physiotherapist’s role, and they will
give further resources to the patient such as an exercise sheet or information on
their condition to give the patient some level of control over the management of
their complaint. Further appointments, if necessary, will be arranged according to
the plan, the physiotherapist and the severity of the condition.
When treatment is complete the patient is discharged back to the referring
consultant and a discharge summary is written to the consultant outlining the
treatment undertaken and the progress to date. This discharge summary is often
manually written and is usually not in a standardised format.
Physiotherapists refer to the evidence base for advice on the most relevant
outcome measures, clinical pathways and the latest evidence. This usually occurs
outside patient treatment times due to time constraints and issues with access to
this information.
Some outpatient physiotherapy departments in Ireland do have electronic referral
systems and outpatient scheduling systems. However, these systems are often not
linked together and there can be duplication of effort with parallel paper based
systems.
Currently in Ireland outpatient physiotherapy departments in acute hospitals have
paper based clinical documentation, referrals onwards, discharge summaries,
157
outcome measures and audit and research processes. In fact, audit and research
can be a long winded paper-based exercise in many physiotherapy departments
due to the lack of adequate electronic databases. This makes it extremely
challenging to review patient outcomes and make improvements. Determining the
profile of patients referred is also a difficulty and this causes problems in
determining staff training needs and service needs e.g. group versus individual
treatment requirements.
Management reports may be possible in the acute hospital outpatient departments
with electronic referral systems and scheduling systems e.g. DNAs (Did Not
Attends), cancellations and number of new and return patients. However, other
metrics such as waiting time (required by the Health Service Executive (HSE) often
continue to be determined through inefficient manual processes.
158
Appendix B: Protocol for semi-structured interviews with
experts
Title of research study
Opportunities for, potential benefits of and challenges to Process Improvement
(based on the introduction of information technology) in an Outpatient
Physiotherapy Department
Lead Researcher
Marie Byrne Date:
Time start: Time finish:
Thank participant for accepting the invitation to participate
So the purpose of this research is determine what if any are the opportunities for
process improvement in the physiotherapy out-patients department, what the
benefits of any improvement initiative would be and what could be the perceived
challenges
Ask participants not to name third parties
You received an e-mail which outlines the detail of the current workflow in the
Physiotherapy out-patients department at St. James’s hospital, Dublin
Where there any steps in the workflow that were unclear?
If yes, please outline
From your review of the workflow please highlight the steps were you believe
processes could be improved
What changes would you suggest to improve the process at each of these steps?
What would the potential benefits be of improving the process at each of these
steps?
What challenges could prevent the realisation of such benefits?
Please outline any key people that you are aware of that have expert knowledge in
this area and who may be willing to participate (snowballing).
159
Appendix C: Consent Form
TRINITY COLLEGE DUBLIN
INFORMED CONSENT FORM
LEAD RESEARCHER: Marie Byrne
BACKGROUND OF RESEARCH:
The purpose of this research study is to carry out a detailed review of opportunities
for, potential benefits of and challenges to process improvement (based on the
introduction of information technology) in the outpatient physiotherapy department
at St. James’s Hospital.
PROCEDURES OF THIS STUDY:
The researcher will carry out a literature review. The research methodology will be
to document a detailed workflow using observation, confirm this workflow with the
physiotherapists and clerical staff involved, carry out semi-structured interviews
with experts in the area and a focus group with key stakeholders to evaluate
potential benefits of automating key points in the workflow and highlight any
possible challenges.
A comprehensive information sheet will be made available to all potential
participants.
PUBLICATION:
The results of the research will be submitted in partial fulfilment of the Masters in
Health Informatics at Trinity College, Dublin. The work may be further developed
with the intention of publication in a peer reviewed journal. The research may be
used by others for academic research. In addition the research outcomes are likely
to be presented at selected conferences, seminars or workshops in Ireland.
The results will be made available to all research participants on completion of the
research study.
DECLARATION:
I am 18 years or older and am competent to provide consent.
160
I have read, or had read to me, a document providing information about this
research and this consent form. I have had the opportunity to ask questions
and all my questions have been answered to my satisfaction and understand
the description of the research that is being provided to me.
I agree that my data is used for scientific purposes and I have no objection
that my data is published in scientific publications in a way that does not
reveal my identity.
I understand that if I make illicit activities known, these will be reported to
appropriate authorities.
I understand that I may stop electronic recordings at any time, and that I
may at any time, even subsequent to my participation have such recordings
destroyed (except in situations such as above).
I understand that, subject to the constraints above, no recordings will be
replayed in any public forum or made available to any audience other than
the current researcher.
I freely and voluntarily agree to be part of this research study, though
without prejudice to my legal and ethical rights.
I understand that I may refuse to answer any question and that I may
withdraw at any time without penalty.
I understand that no personal details about me will be recorded.
I have received a copy of this agreement.
PARTICIPANT’S NAME: PARTICIPANT’S SIGNATURE:
Date:
______________________ _____________________________
Statement of investigators’ responsibility: I have explained the nature and
purpose of this research, the procedures to be undertaken and any risks that may
be involved. I have offered to answer any questions and fully answered such
161
questions. I believe that the participant understands my explanation and has freely
given informed consent.
RESEARCHERS CONTACT DETAILS: [email protected] or by phone: 01
4162486
INVESTIGATORS’ SIGNATURE: Date:
_________________________________________________________
Marie Byrne
162
Appendix D: Participant Information Sheets
TRINITY COLLEGE DUBLIN
INFORMATION SHEET FOR PARTICIPANTS – OBSERVATION OF WORKFLOW
Dear Colleague,
I would like to invite you to take part in a research study entitled “Opportunities
for, potential benefits of and challenges to process improvement (based on the
introduction of information technology) in the outpatient physiotherapy department
at St. James’s Hospital”. This research is being undertaken as part fulfilment of an
MSc in Health Informatics in Trinity College Dublin (TCD).
Please read the following information carefully and ask if you do not understand
any part of it or would like more information.
Who is organising the research study?
This research study is being undertaken by Ms. Marie Byrne as part of an MSc in
Health Informatics in Trinity College, Dublin.
The study will be completed between January and May 2013.
Why have I been chosen?
We are inviting you to participate in this study as you are familiar with the current
processes in the outpatient physiotherapy department at St. James’s Hospital.
Background of research:
This research study is concerned with a detailed review of the workflow in an
outpatient physiotherapy setting to seek out opportunities for, potential benefits of
and challenges to process improvement (based on the introduction of information
technology).
The overall aim of this research is to provide a roadmap to process improvement in
outpatient physiotherapy and similar settings as there is a very limited research
base in this area.
Objectives:
• To outline the goals of process improvement
• To map out the current workflow from patient referral to discharge and/or
onward referral
• To validate this workflow with relevant team members to ensure the current
situation is accurately reflected in the workflow
• To collect baseline data to allow for benefit realisation studies to take place
in the future
• To highlight process improvement opportunities
• To determine potential benefits of any process improvements
163
• To outline possible challenges
What is the purpose of the research study?
The purpose of this study is to review opportunities for process improvement
(based on the introduction of information technology) along the physiotherapy out-
patient pathway, to outline potential benefits of any change and to highlight any
challenges that may exist to prevent realisation of such benefits.
What will happen to me if I take part?
You will be observed carrying out your work in order to clearly document the
current workflow/processes and you will be asked to confirm the workflow
documented by the researcher afterwards
What will happen to the results of the research study?
The results of the research will serve to inform the researcher of opportunities for
the introduction of IT, the benefits of such an introduction and the possible
challenges to realization of such benefits.
The results of the study will be submitted as part of the TCD masters programme.
The work may be further developed with the intention of publication in a peer
reviewed journal. The research may be used by others for academic research. In
addition the research outcomes are likely to be presented at selected conferences,
seminars or workshops in Ireland.
The results can be made available to all research participants on completion of the
research study.
Confidentiality - who will know I am taking part in the research study?
All information, which is collected during the course of the research, will be kept
strictly confidential.
Conflict of interest:
The main researcher is a physiotherapy manager in the physiotherapy department
in which the research will be undertaken.
Expected duration:
It will take approximately 45 minutes for the researcher to complete each
observation.
Confirmation of workflow will take a further 15 minutes.
Procedure to be used if assistance or advice is needed
In the event that you require further information about this study please contact
Marie Byrne who will be happy to answer your questions. Marie can be contacted by
email: [email protected] or by phone: 01 4162486.
164
Voluntary Participation
Your participation in this study is voluntary and you are free to withdraw at any
time without providing a reason. If you are happy to participate please complete
the attached consent form and return to Ms. Marie Byrne before taking part. Thank
you for taking the time to read this correspondence and for considering taking part
in this research.
Yours sincerely
Marie Byrne
TRINITY COLLEGE DUBLIN
INFORMATION SHEET FOR PARTICIPANTS – SEMI-STRUCTURED
INTERVIEWS
Dear Colleague,
I would like to invite you to take part in a research study entitled “Opportunities
for, potential benefits of and challenges to process improvement (based on the
introduction of information technology) in the outpatient physiotherapy department
at St. James’s Hospital”. This research is being undertaken as part fulfilment of an
MSc in Health Informatics in Trinity College Dublin (TCD).
Please read the following information carefully and ask if you do not understand
any part of it or would like more information.
Who is organising the research study?
This research study is being undertaken by Ms. Marie Byrne as part of an MSc in
Health Informatics in Trinity College, Dublin.
The study will be completed between January and May 2013.
Why have I been chosen?
We are inviting you to participate in this study as you have carried out a process
improvement initiative in a physiotherapy or another similar setting.
Background of research:
This research study is concerned with a detailed review of the workflow in an
outpatient physiotherapy setting to seek out opportunities for, potential benefits of
and challenges to process improvement (based on the introduction of information
technology).
The overall aim of this research is to provide a roadmap to process improvement in
outpatient physiotherapy and similar settings as there is a very limited research
base in this area.
Objectives:
165
• To outline the goals of process improvement
• To map out the current workflow from patient referral to discharge and/or
onward referral
• To validate this workflow with relevant team members to ensure the current
situation is accurately reflected in the workflow
• To collect baseline data to allow for benefit realisation studies to take place
in the future
• To highlight process improvement opportunities
• To determine potential benefits of any process improvements
• To outline possible challenges
What is the purpose of the research study?
The purpose of this study is to review opportunities for process improvement
(based on the introduction of information technology) along the physiotherapy out-
patient pathway, to outline potential benefits of any change and to highlight any
challenges that may exist to prevent realisation of such benefits.
What will happen to me if I take part?
You will be e-mailed the detail of the current workflow in the outpatient
physiotherapy department at St. James’s Hospital to review. The researcher will
then carry out a semi-structured telephone interview with you where you will be
asked to highlight opportunities for, benefits of and challenges to process
improvement as you see them. The researcher will take written notes of the
interview, transcribe these notes into a soft copy format and e-mail the notes to
you to confirm their accuracy.
What will happen to the results of the research study?
The results of the research will serve to inform the researcher of opportunities for
the introduction of IT, the benefits of such an introduction and the possible
challenges to realization of such benefits.
The results of the study will be submitted as part of the TCD masters programme.
The work may be further developed with the intention of publication in a peer
reviewed journal. The research may be used by others for academic research. In
addition the research outcomes are likely to be presented at selected conferences,
seminars or workshops in Ireland.
The results can be made available to all research participants on completion of the
research study.
Confidentiality - who will know I am taking part in the research study?
All information, which is collected during the course of the research, will be kept
strictly confidential.
Conflict of interest:
166
The main researcher is a physiotherapy manager in the physiotherapy department
in which the research will be undertaken.
Expected duration:
It will take approximately one hour to complete each interview.
Procedure to be used if assistance or advice is needed
In the event that you require further information about this study please contact
Marie Byrne who will be happy to answer your questions. Marie can be contacted by
email: [email protected] or by phone: 01 4162486.
Voluntary Participation
Your participation in this study is voluntary and you are free to withdraw at any
time without providing a reason. If you are happy to participate please complete
the attached consent form and return to Ms. Marie Byrne before taking part. Thank
you for taking the time to read this correspondence and for considering taking part
in this research.
Yours sincerely
Marie Byrne
TRINITY COLLEGE DUBLIN
INFORMATION SHEET FOR PARTICIPANTS – FOCUS GROUP
Dear Colleague,
I would like to invite you to take part in a research study entitled “Opportunities
for, potential benefits of and challenges to process improvement (based on the
introduction of information technology) in the outpatient physiotherapy department
at St. James’s Hospital”. This research is being undertaken as part fulfilment of an
MSc in Health Informatics in Trinity College Dublin (TCD).
Please read the following information carefully and ask if you do not understand
any part of it or would like more information.
Who is organising the research study?
This research study is being undertaken by Ms. Marie Byrne as part of an MSc in
Health Informatics in Trinity College, Dublin.
The study will be completed between January and May 2013.
Why have I been chosen?
167
We are inviting you to participate in this study as you are familiar with the current
processes in the outpatient physiotherapy department at St. James’s Hospital or
have an interest in information technology in this or another setting.
Background of research:
This research study is concerned with a detailed review of the workflow in an
outpatient physiotherapy setting to seek out opportunities for, potential benefits of
and challenges to process improvement (based on the introduction of information
technology).
The overall aim of this research is to provide a roadmap to process improvement in
outpatient physiotherapy and similar settings as there is a very limited research
base in this area.
Objectives:
• To outline the goals of process improvement
• To map out the current workflow from patient referral to discharge and/or
onward referral
• To validate this workflow with relevant team members to ensure the current
situation is accurately reflected in the workflow
• To collect baseline data to allow for benefit realisation studies to take place
in the future
• To highlight process improvement opportunities
• To determine potential benefits of any process improvements
• To outline possible challenges
What is the purpose of the research study?
The purpose of this study is to review opportunities for process improvement
(based on the introduction of information technology) along the physiotherapy out-
patient pathway, to outline potential benefits of any change and to highlight any
challenges that may exist to prevent realisation of such benefits.
What will happen to me if I take part?
You will be involved in a focus group to review the workflow with approximately five
other participants. Participants will be asked to highlight opportunities for process
improvement along with potential benefits and challenges. The focus group will be
recorded on a Dictaphone and the researcher will take written notes.
What will happen to the results of the research study?
The results of the research will serve to inform the researcher of opportunities for
the introduction of IT, the benefits of such an introduction and the possible
challenges to realization of such benefits.
The results of the study will be submitted as part of the TCD masters programme.
The work may be further developed with the intention of publication in a peer
168
reviewed journal. The research may be used by others for academic research. In
addition the research outcomes are likely to be presented at selected conferences,
seminars or workshops in Ireland.
The results can be made available to all research participants on completion of the
research study.
Confidentiality - who will know I am taking part in the research study?
All information, which is collected during the course of the research, will be kept
strictly confidential.
Conflict of interest:
The main researcher is a physiotherapy manager in the physiotherapy department
in which the research will be undertaken.
Expected duration:
The focus group will take a maximum of two hours.
Procedure to be used if assistance or advice is needed
In the event that you require further information about this study please contact
Marie Byrne who will be happy to answer your questions. Marie can be contacted by
email: [email protected] or by phone: 01 4162486.
Voluntary Participation
Your participation in this study is voluntary and you are free to withdraw at any
time without providing a reason. If you are happy to participate please complete
the attached consent form and return to Ms. Marie Byrne before taking part. Thank
you for taking the time to read this correspondence and for considering taking part
in this research.
Yours sincerely
Marie Byrne
169
Appendix E:
Ethics
170
171
172
Appendix F: Key to notations on process maps
A-REFERRAL MANAGEMENT AND TRIAGE
A1 Referral to physiotherapy is placed on the EPR (Cerner Electronic Patient Record) by an
internal consultant or physiotherapist (at fracture clinics)
A2 An EPR referral is not currently generated for external referrals (GP referrals for staff
and patient referrals from other hospitals) so the paper referral for these categories
arrives in the post or is handed in by the patient (make up less than 5% of referrals)
A3 Paper referrals are lifted from the printer by the clerical staff
It takes an average of 10.5 seconds to complete steps A3, A4 and A5 for each referral.
These are steps are carried out on a batch of referrals rather than individual referrals.
A4 Clerical staff log on to the EPR, enter the patient’s MRN and “complete” in message
centre list. This indicates to the referrer that the referral has been received in
physiotherapy
A5 Paper referrals that have been “completed” on the EPR by the clerical staff are carried
from reception and put in a tray in the main physiotherapy out-patient department
A6 The paper referrals (from external source and internal (EPR)) are triaged by a senior
physiotherapist
A7 The physiotherapist decides whether the referral is “Urgent”, “Routine” or “Fracture”
or to be referred locally/to community (note there are 4 triaging categories) and writes
this on the paper referral
A8 Using a physiotherapy coding system the physiotherapist determines the anatomy and
pathology of the reason for referral and writes this on the paper referral. Each referral
will have a 2 or 3 character code written on it
A9 Paper referrals that have been triaged by the physiotherapist are carried from the
main physiotherapy outpatients area and put in a tray in the physiotherapy reception
It takes an average of 39.38 seconds to complete steps A6, A7, A8 and A9 for each
referral. These are steps are carried out on a batch of referrals rather than individual
referrals. As for steps A3, A4 and A5 one referral would involve as much walking as 10
or 20. Some referrals are difficult to triage and code due to the limited amount of
173
information on them and so further background information on the patient is sought
from the EPR (scans, x-rays, correspondence)
A10 The clerical staff enter the referral details on an Excel waiting list spread sheet. This
involves transcribing all of the details on the paper referral in to the spread sheet. The
spread sheet is saved on the physiotherapy department G Drive and is a list of all
referrals to physiotherapy out-patients
A11 Once entered on the spread sheet the paper referrals are separated into routine and
urgent and those to be referred to community/locally. The routine and urgent referrals
are put into separate manual folders. Fracture (#) clinic referrals get a new file made
up for each of them as they don’t go on the waiting list as have return appointments.
Fracture clinic patients are patients that are seen by a physiotherapist attending a
consultant orthopaedic clinic where the patient is seen directly by the physiotherapist
for advice and exercise and given a follow-up appointment in the main physiotherapy
out-patients department before they leave the # clinic
It takes an average of 38.7 seconds to complete steps A10 and A11 for each referral.
These are steps are carried out on a batch of referrals rather than individual referrals.
A12 If a patient is referred onwards to the community services or their local hospital they
exit the workflow at this point and are discharged
B (a)-WAITING LIST MANAGEMENT AND APPOINMTENT BOOKING
There is some variation between the clerical staff as to what happens when the appointment is
allocated
B (a) 1 The manual waiting list folders (paper referrals in standard folders) are reviewed by
the clerical staff in conjunction with free new patient slots on the PAS
OR
B (a) 2 The clerical staff review all of the new patient slots in all clinics on the PAS for the
coming 3 weeks. This involves going into each clinic individually then each day
individually
B (a) 3 Any new slots that are free are documented on a piece of paper
B (a) 4 The manual waiting lists are then reviewed to determine which patients are next in
line for appointments
174
B (a) 5 The clerical staff ring the next patient on the manual waiting list
B (a) 6 The patient tells the clerical staff member they no long need physiotherapy or they
wish to be referred locally
B (a) 7 The clerical staff book patients in to all of the available clinic slots on the PAS
B (a) 8 Following the printing of all clinic lists and pulling of physiotherapy notes [ which
happens on a daily basis for the following day] the clerical staff review the clinic lists
and determine which return slots are free. Return slots are set up on creation of a
clinic template to allow patients returning to physiotherapy out-patients to be booked
in as needed
B (a) 9 The need for a follow-up appointment at the end of a scheduled appointment is based
on clinical need which is determined by the physiotherapist
B (a) 10 Patients book another appointment as required before leaving the department
The average time to carry out this task is outlined as 60.64 seconds (range 20.25 – 124.9
seconds).
B (b) – WAITING LIST DATA
B (b) 1 Each month physiotherapy management request data on the length of the waiting list
and the numbers waiting in various categories 0-2 weeks, 3-6 weeks, 7-10 weeks. This
information is manually calculated from the manual waiting list folders that store the
paper referrals. The information on the length of the waiting list and the numbers
waiting is entered into an Excel waiting list spread sheet. This spread sheet divides the
waiting list up per consultant, per specialty and outlines the numbers waiting in each
of the HSE categories. This information is required for HSE CompStat and is
benchmarked against 29 hospitals nationally
B (b) 2 The manual waiting list folders are reviewed. This is a completely manual process
B (b) 3 The number of referrals in each of the folders is manually counted
B (b) 4 Waiting time is calculated for urgent and routine referrals. This is done by calculating
the time of referral to today for the longest person waiting in each of the triage
categories
175
B (b) 5 Data on numbers in each category and time to routine and urgent appointment are
entered on the Excel waiting list spread sheet
B (b) 6 A patient phones the department asking when they will receive an appointment
B (b) 7 The clerical staff ask the patient when they were seen at the consultant clinic
B (b) 8 The clerical staff review the EPR to determine if a referral was placed
B (b) 9 The clerical staff check the manual waiting list folder to determine if the referral is
there
B (b) 10 The clerical staff review the spread sheet with all the referral details to ensure a
referral was received
B (b) 11 Patient advised that their referral has been received and is told length of waiting list
B (b) 12Patient advised no referral received and they need to go back to their consultant
B (b) 13The clerical staff refer to the PAS to determine when the patient was at the
consultant’s clinic if the patient does not know
C (a)-PATIENT ATTENDANCE
C (a) 1 The patient receives a reminder text message for all appointments 5 days in advance.
This reminder is set up in an Outpatient Reminder System (ORPS) which is linked to the
PAS
C (a) 2 The patient arrives in to the physiotherapy out-patient department
C (a) 3 The clerical staff determine if this is the patient’s first appointment
C (a) 4 The patient is registered to the relevant clinic on the PAS as a NEW attendance with
the clerical staff confirming the patient’s details (e.g. mobile phone number)
C (a) 5 The clerical staff retrieve the patient’s referral from the new referrals box
C (a) 6 A front sheet is printed from the PAS. This sheet outlines the patient’s personal details
including GP, medical card number and attendances at consultant out-patient clinics
C (a) 7 Department policies are outlined to the patient and a copy given to the patient with a
yellow appointment card
176
C (a) 8 The clerical staff make up physiotherapy notes which include the referral, front sheet,
an assessment sheet, a database and continuation sheets and walk through to the
main department to give the notes to the physiotherapist
C (a) 9 The patient is registered to the relevant clinic on the PAS as a RETURN attendance
C (a) 10 The physiotherapist treats the patient for the duration of their scheduled appointment
C (a) 11 A decision is made by the physiotherapist based on the patient’s clinical need that
further treatment is or is not require
C (b) PATIENT NON-ATTENDANCE
Did Not Attends (DNA)
C (b) 1 Patient does not attend (DNA) for their scheduled physiotherapy out-patient
appointment so they are not registered on the PAS
C (b) 2 This DNA is automatically registered on the PAS 24 hours after the scheduled
appointment time
C (b) 3 The physiotherapist determines if this is the patient’s first appointment – if it is they
are discharged as per policy.
C (b) 4 If it is not the patient’s first appointment they are given two weeks to make a further
appointment before they are discharged
Cancellations
C (b) 5 Patient rings to cancel a scheduled appointment
C (b) 6 Patient determines no further treatment is required so they self-discharge
C (b) 7 The patient makes another appointment directly at the time of cancelling
C (b) 8 The physiotherapist determines if this is the third consecutive cancellation recorded
on the PAS and if so the patient is discharged
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D-DISCHARGE
D1 The physiotherapist decides if a referral to community is most appropriate
D2 The physiotherapist decides if a referral to the patient’s local hospital is most
appropriate
D3 The physiotherapist prints off any relevant x-ray/scan results from the EPR and
attaches these to the referral
D4 The referral with all relevant details attached is posted to the patient’s local
hospital/community care area
D5 Community care area is based on the patient’s address and it is necessary to look up a
street index to determine the correct area. This is a manual process which involves
accessing a separate PDF document. This is carried out by the physiotherapist
D6 The patient is informed by posted letter that they have been referred to their
community service
D7 Details of all referrals to the community are entered into the community referrals
Excel database
D8 Patient Discharged is written on the referral/physiotherapy notes
D9 Referrals/physiotherapy notes are filed away in the current year archive
The physiotherapist does not routinely write a discharge letter or update letter to the referrer
(since Nov ’12 due to lack of clerical capacity)
Exceptions:
If the physiotherapist feels the patient needs to access further investigations (MRI) or
needs further interventions (Injections)
If the patient is unsuitable for physiotherapy
E-RETRIEVING AND FILING NOTES
E1 Each day the physiotherapists file away return patient physiotherapy notes
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E2 Each day the clerical staff file away new patient physiotherapy notes (a new file needs
to be made up for these patients)
E3 Each day the clerical staff retrieve physiotherapy notes for all of the patients due to
attend the next day. This is based on the clinic list for each clinic which is printed off
the PAS. The notes are stored in the main reception area and are filed by clinic,
alphabetically. It takes an average of 10.44 seconds to retrieve each file (an average of
25 files are retrieved daily)
E4 As time allows the clerical staff archive physiotherapy notes of patients who have been
discharged. The current year notes are stored in an office beside the main reception
area. It takes an average of 16.3 seconds to file each set of notes
E5 Medico legal requests including; Freedom of Information (FOI), Routine Access and
Medico legal reports require the clerical staff to retrieve the relevant patient notes.
These notes might be filed in the current year archive or old archive
E6 If a patient DNAs their appointment the physiotherapist does not file the notes away.
These notes are kept for 2 weeks in a DNA box and then discharged if the patient has
not made another appointment within that time frame
E7 If a patient Cancels their appointment and does not wish/need to make another
appointment the physiotherapist removes these notes from the active notes
immediately and they are discharged
E8 If a patient Cancels their appointment and does not make another appointment for 2
weeks their notes are removed from the active notes by the physiotherapist as time
allows and they are filed away with the discharged notes. When they are removed
from the active files is adhoc and involves the physiotherapist going through their
clinic files one by one
179
Appendix G: Stakeholder Analysis
Stakeholder
Patient
Physiotherapists
Clerical Staff
Physiotherapy Managers internal
Physiotherapy Managers external (29 acute hospitals compared)
Senior Management
HSE staff
IT staff
Finance staff
Community
Other hospitals
All consultants currently referring and who may refer in the future
180
Appendix H: Draft Benefits Realisation Plan
Benefits Measures
Decrease in waiting time for patients
Improved patient outcomes as
patients don’t become chronic while
waiting
Reduced time to triage referrals for
physiotherapists and clerical staff
Decreased cost of paper and printing
components
Decreased time spent retrieving and
filing notes
Reduction in number of unanswered
calls
Easier access to information
Numbers waiting
Waiting times
Throughput (new patients seen and
New: Return ratios)
New: Return ratios
Reduction in number of steps in
process and actual time to complete
triaging
Total cost
Number of notes filed and retrieved
Time spent
% of calls unanswered
Staff satisfaction with information
access
Staff presentation of data retrieved
181
Improved staff satisfaction
Improved Patient satisfaction
Close off of patient attendance
Decreased non-clinical activity for
physiotherapists
for annual reports/audits
Survey
Survey
Discharge summaries
Review of process steps and timings